05D1097025 CLIA NUMBER - MONTECRISTO MEDICAL PC

Laboratory Demographics

  • CLIA Code: 05D1097025
  • Facility Name: MONTECRISTO MEDICAL PC
  • Facility Address: 14649 VICTORY BLVD SUITE 20
    VAN NUYS, CA
    ZIP 91401
  • Facility Phone: 818 786-8396
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: ANITA E. GONZALEZ, MD
  • NPI Number: 1699268631
  • Taxonomy: 261QP2300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 05D1097025
LAB Type Physician Office
Facility Name MONTECRISTO MEDICAL PC
Street 14649 VICTORY BLVD SUITE 20
City VAN NUYS
State CA
ZIP 91401
Phone 818 786-8396
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/17/2025
Certificate Expiration Date 3/16/2027
Facility Type Physician Office
Lab Director ANITA E. GONZALEZ, MD

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This page was last updated on: 9/29/2025