05D2194751 CLIA NUMBER - PREMIER SURGICAL PAVILION OF LOS ANGELES

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Laboratory Demographics

CLIA Number: 05D2194751

Facility Name: PREMIER SURGICAL PAVILION OF LOS ANGELES

Facility Address:
11661 SAN VICENTE BOULEVARD
LOS ANGELES, CA
ZIP 90049
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Facility Phone Number: 917 942-0635

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1114589793

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D2194751
LAB Type	Ambulatory Surgery Center
Facility Name	PREMIER SURGICAL PAVILION OF LOS ANGELES
Street	11661 SAN VICENTE BOULEVARD
City	LOS ANGELES
State	CA
ZIP	90049
Phone	917 942-0635
CertificateType	4
CertificateEffectiveDate	10/2/2022
CertificateExpirationDate	10/1/2024
FacilityType	Waiver

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