05D2145701 CLIA NUMBER - SOURCE SURGERY CENTER LLC

Laboratory Demographics

  • CLIA Code: 05D2145701
  • Facility Name: SOURCE SURGERY CENTER LLC
  • Facility Address: 2801 WILSHIRE BLVD
    SANTA MONICA, CA
    ZIP 90403
  • Facility Phone: 310 574-2777
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: TIMOTHY T. DAVIS
  • NPI Number: 1558802249
  • Taxonomy: 261QA1903X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 05D2145701
LAB Type Ambulatory Surgery Center
Facility Name SOURCE SURGERY CENTER LLC
Street 2801 WILSHIRE BLVD
City SANTA MONICA
State CA
ZIP 90403
Phone 310 574-2777
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/13/2024
Certificate Expiration Date 3/12/2026
Facility Type Ambulatory Surgery Center
Lab Director TIMOTHY T. DAVIS

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