39D2145232 CLIA NUMBER - INNOVAGE PENNSYLVANIA LIFE ST BART'S

Laboratory Demographics

CLIA Code: 39D2145232
Facility Name: INNOVAGE PENNSYLVANIA LIFE ST BART'S
Facility Address: 5364 JACKSON STREET
PHILADELPHIA, PA
ZIP 19124
Facility Phone: 303 600-6930
Facility Type: Physician Office
Facility Type: Waiver
Lab Director: DR. LUZ S. RAMOS-BONNER
NPI Number: 1467056655
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	39D2145232
LAB Type	Physician Office
Facility Name	INNOVAGE PENNSYLVANIA LIFE ST BART'S
Street	5364 JACKSON STREET
City	PHILADELPHIA
State	PA
ZIP	19124
Phone	303 600-6930
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	3/5/2024
Certificate Expiration Date	3/4/2026
Facility Type	Physician Office
Lab Director	DR. LUZ S. RAMOS-BONNER

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This page was last updated on: 6/4/2025