39D1100989 CLIA NUMBER - TEMPLE FAMILY MEDICINE - OLD BUSTLETON

Laboratory Demographics

  • CLIA Code: 39D1100989
  • Facility Name: TEMPLE FAMILY MEDICINE - OLD BUSTLETON
  • Facility Address: 9331 OLD BUSTLETON AVENUE SUITE 100
    PHILADELPHIA, PA
    ZIP 19115
  • Facility Phone: 215 671-0653
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: DR. RAQUEL A. INNISS
  • NPI Number: 1164841946
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 39D1100989
LAB Type Physician Office
Facility Name TEMPLE FAMILY MEDICINE - OLD BUSTLETON
Street 9331 OLD BUSTLETON AVENUE SUITE 100
City PHILADELPHIA
State PA
ZIP 19115
Phone 215 671-0653
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/18/2025
Certificate Expiration Date 6/17/2027
Facility Type Physician Office
Lab Director DR. RAQUEL A. INNISS

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