05D2181031 CLIA NUMBER - KINTSUGI SURGICAL LLC

Laboratory Demographics

  • CLIA Code: 05D2181031
  • Facility Name: KINTSUGI SURGICAL LLC
  • Facility Address: 1127 WILSHIRE BLVD, SUITE 1000A
    LOS ANGELES, CA
    ZIP 90017
  • Facility Phone: 213 328-3600
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: DEREK T. DEE MD
  • NPI Number: 1154846111
  • Taxonomy: 261QA1903X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 05D2181031
LAB Type Ambulatory Surgery Center
Facility Name KINTSUGI SURGICAL LLC
Street 1127 WILSHIRE BLVD, SUITE 1000A
City LOS ANGELES
State CA
ZIP 90017
Phone 213 328-3600
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/25/2024
Certificate Expiration Date 3/24/2026
Facility Type Ambulatory Surgery Center
Lab Director DEREK T. DEE MD

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