05D2230674 CLIA NUMBER - OC TEEN CENTER LLC

Laboratory Demographics

CLIA Number: 05D2230674

Facility Name: OC TEEN CENTER LLC

Facility Address:
3188 AIRWAY AVE UNIT L
COSTA MESA, CA
ZIP 92626
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Facility Phone Number: 855 925-5309

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1528650686

Taxonomy: 261QM0855X - Clinic/Center
An entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to mental and behavioral disorders in children and adolescents. Services may be provided to parents and family members of the patient in the form of conjoint, group, or individual therapy, and education and/or training.

CLIA Record

Field Name	Field Value
CLIA Number	05D2230674
LAB Type	Physician Office
Facility Name	OC TEEN CENTER LLC
Street	3188 AIRWAY AVE UNIT L
City	COSTA MESA
State	CA
ZIP	92626
Phone	855 925-5309
CertificateType	4
CertificateEffectiveDate	7/27/2023
CertificateExpirationDate	7/26/2025
FacilityType	Waiver

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