05D2069763 CLIA NUMBER - PINE STREET CLINIC

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Laboratory Demographics

CLIA Number: 05D2069763

Facility Name: PINE STREET CLINIC

Facility Address:
408 PINE ST
MOUNT SHASTA, CA
ZIP 96067
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Facility Phone Number: 530 926-9334

Facility Type: Community Clinic

Certificate Type: Microscopy

NPI Number: 1942632534

Taxonomy: 261QR1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D2069763
LAB Type	Community Clinic
Facility Name	PINE STREET CLINIC
Street	408 PINE ST
City	MOUNT SHASTA
State	CA
ZIP	96067
Phone	530 926-9334
CertificateType	3
CertificateEffectiveDate	12/3/2023
CertificateExpirationDate	12/2/2025
FacilityType	PPMP

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