05D2200588 CLIA NUMBER - ST. GRACE MANOR, INC

Laboratory Demographics

  • CLIA Code: 05D2200588
  • Facility Name: ST. GRACE MANOR, INC
  • Facility Address: 4440 FAUNA STREET
    MONTCLAIR, CA
    ZIP 91763
  • Facility Phone: 909 577-0110
  • Facility Type: Intermediate Care Facility for Mentally Retarded
  • Facility Type: Waiver
  • Lab Director: MALLY REDLEY
  • NPI Number: 1164964383
  • Taxonomy: 313M00000X - Nursing Facility/Intermediate Care Facility

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CLIA Record

Field Name Field Value
CLIA Number 05D2200588
LAB Type Intermediate Care Facility for Mentally Retarded
Facility Name ST. GRACE MANOR, INC
Street 4440 FAUNA STREET
City MONTCLAIR
State CA
ZIP 91763
Phone 909 577-0110
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/16/2024
Certificate Expiration Date 11/15/2026
Facility Type Intermediate Care Facility for Mentally Retarded
Lab Director MALLY REDLEY

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