05D2095375 CLIA NUMBER - EASTVALE MEDICAL GROUP

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Laboratory Demographics

CLIA Number: 05D2095375

Facility Name: EASTVALE MEDICAL GROUP

Facility Address:
12523 LIMONITE AVE STE 400
MIRA LOMA, CA
ZIP 91752
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Facility Phone Number: 951 808-6300

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1396403267

Taxonomy: 261QA0600X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D2095375
LAB Type	Physician Office
Facility Name	EASTVALE MEDICAL GROUP
Street	12523 LIMONITE AVE STE 400
City	MIRA LOMA
State	CA
ZIP	91752
Phone	951 808-6300
CertificateType	4
CertificateEffectiveDate	5/6/2023
CertificateExpirationDate	5/5/2025
FacilityType	Waiver

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