05D2023758 CLIA NUMBER - PROHEALTH GLENDALE OCCUPATIONAL MEDICAL GROUP

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Laboratory Demographics

CLIA Number: 05D2023758

Facility Name: PROHEALTH GLENDALE OCCUPATIONAL MEDICAL GROUP

Facility Address:
500 E. COLORADO STREET, SUITE 100
GLENDALE, CA
ZIP 91205
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Facility Phone Number: 818 246-4800

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1376819821

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D2023758
LAB Type	Physician Office
Facility Name	PROHEALTH GLENDALE OCCUPATIONAL MEDICAL GROUP
Street	500 E. COLORADO STREET, SUITE 100
City	GLENDALE
State	CA
ZIP	91205
Phone	818 246-4800
CertificateType	4
CertificateEffectiveDate	4/29/2023
CertificateExpirationDate	4/28/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024