39D2002622 CLIA NUMBER - LIFE ST MARY

Laboratory Demographics

CLIA Code: 39D2002622
Facility Name: LIFE ST MARY
Facility Address: 2500 NORTHGATE ROAD
TREVOSE, PA
ZIP 19053
Facility Phone: 267 991-7620
Facility Type: Physician Office
Facility Type: Waiver
Lab Director: DR. ANTONIA SOJAN
NPI Number: 1003052820
Taxonomy: 251T00000X - Program of All-Inclusive Care for the Elderly (PACE) Provider Organization

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CLIA Record

Field Name	Field Value
CLIA Number	39D2002622
LAB Type	Physician Office
Facility Name	LIFE ST MARY
Street	2500 NORTHGATE ROAD
City	TREVOSE
State	PA
ZIP	19053
Phone	267 991-7620
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	1/22/2024
Certificate Expiration Date	1/21/2026
Facility Type	Physician Office
Lab Director	DR. ANTONIA SOJAN

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