05D2283520 CLIA NUMBER - PROVIDENCE ADVANTAGE

Laboratory Demographics

  • CLIA Code: 05D2283520
  • Facility Name: PROVIDENCE ADVANTAGE
  • Facility Address: 19333 BEAR VALLEY #101
    APPLE VALLEY, CA
    ZIP 92308
  • Facility Phone: 760 261-5023
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: MINO PHAM
  • NPI Number: 1053616706
  • Taxonomy: 208800000X - Urology

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CLIA Record

Field Name Field Value
CLIA Number 05D2283520
LAB Type Physician Office
Facility Name PROVIDENCE ADVANTAGE
Street 19333 BEAR VALLEY #101
City APPLE VALLEY
State CA
ZIP 92308
Phone 760 261-5023
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/8/2025
Certificate Expiration Date 6/7/2027
Facility Type Physician Office
Lab Director MINO PHAM

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