05D2019393 CLIA NUMBER - MEMORIALCARE MEDICAL GROUP

Laboratory Demographics

  • CLIA Code: 05D2019393
  • Facility Name: MEMORIALCARE MEDICAL GROUP
  • Facility Address: 18111 BROOKHURST ST, STE 6100
    FOUNTAIN VALLEY, CA
    ZIP 92708
  • Facility Phone: 714 378-7330
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: JACK F. JACOUB MD
  • NPI Number: 1912653288
  • Taxonomy: 332900000X - Non-Pharmacy Dispensing Site

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CLIA Record

Field Name Field Value
CLIA Number 05D2019393
LAB Type Physician Office
Facility Name MEMORIALCARE MEDICAL GROUP
Street 18111 BROOKHURST ST, STE 6100
City FOUNTAIN VALLEY
State CA
ZIP 92708
Phone 714 378-7330
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/1/2025
Certificate Expiration Date 1/31/2027
Facility Type Physician Office
Lab Director JACK F. JACOUB MD

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