12D1079401 CLIA NUMBER - PEARL CITY SPECIALIZED RESIDENTIAL SVCS PROGRAM

Laboratory Demographics

CLIA Code: 12D1079401
Facility Name: PEARL CITY SPECIALIZED RESIDENTIAL SVCS PROGRAM
Facility Address: 1668 HO'OHULU ST
PEARL CITY, HI
ZIP 96782
Facility Phone: 808 773-7390
Facility Type: Other - SRSP
Facility Type: Waiver
Lab Director: JENNIFER SIATAFU
NPI Number: 1194140251
Taxonomy: 320800000X - Community Based Residential Treatment Facility, Mental Illness

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CLIA Record

Field Name	Field Value
CLIA Number	12D1079401
LAB Type	Other - SRSP
Facility Name	PEARL CITY SPECIALIZED RESIDENTIAL SVCS PROGRAM
Street	1668 HO'OHULU ST
City	PEARL CITY
State	HI
ZIP	96782
Phone	808 773-7390
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	6/17/2025
Certificate Expiration Date	6/16/2027
Facility Type	Other - SRSP
Lab Director	JENNIFER SIATAFU

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