05D2135654 CLIA NUMBER - REALITOS DIVISION

Laboratory Demographics

CLIA Number: 05D2135654

Facility Name: REALITOS DIVISION

Facility Address:
612 REALITOS ST
LA VERNE, CA
ZIP 91750
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Facility Phone Number: 909 912-5639

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1912159385

Taxonomy: 320900000X - Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities.

CLIA Record

Field Name	Field Value
CLIA Number	05D2135654
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	REALITOS DIVISION
Street	612 REALITOS ST
City	LA VERNE
State	CA
ZIP	91750
Phone	909 912-5639
CertificateType	4
CertificateEffectiveDate	8/24/2023
CertificateExpirationDate	8/23/2025
FacilityType	Waiver

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