05D2177314 CLIA NUMBER - SO CAL BEHAVIORAL MEDICINE

Laboratory Demographics

  • CLIA Code: 05D2177314
  • Facility Name: SO CAL BEHAVIORAL MEDICINE
  • Facility Address: 1711 VIA EL PRADO SUITE 301
    REDONDO BEACH, CA
    ZIP 90277
  • Facility Phone: 310 698-5252
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: SHAHROUZ Y. GHODSIAN
  • NPI Number: 1134691124
  • Taxonomy: 363LP0808X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 05D2177314
LAB Type Physician Office
Facility Name SO CAL BEHAVIORAL MEDICINE
Street 1711 VIA EL PRADO SUITE 301
City REDONDO BEACH
State CA
ZIP 90277
Phone 310 698-5252
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/8/2024
Certificate Expiration Date 1/7/2026
Facility Type Physician Office
Lab Director SHAHROUZ Y. GHODSIAN

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