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05D2200588 CLIA NUMBER - ST. GRACE MANOR, INC

Laboratory Demographics

CLIA Number: 05D2200588

Facility Name: ST. GRACE MANOR, INC

Facility Address:
4440 FAUNA STREET
MONTCLAIR, CA
ZIP 91763
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Facility Phone Number: 909 577-0110

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver
NPI Number: 1164964383

Taxonomy: 313M00000X - Nursing Facility/Intermediate Care Facility
An institution (or a distinct part of an institution) which- (1) is primarily engaged in providing to residents- (A) skilled nursing care and related services for residents who require medical or nursing care, (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; (2) has in effect a transfer agreement with one or more hospitals.

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
CertificateType 4
CertificateEffectiveDate 11/16/2022
CertificateExpirationDate 11/15/2024
FacilityType Waiver

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