45D2047058 CLIA NUMBER - SUN CITY SPORTS MEDICINE AND FAMILY CLINIC,PA

Laboratory Demographics

  • CLIA Code: 45D2047058
  • Facility Name: SUN CITY SPORTS MEDICINE AND FAMILY CLINIC,PA
  • Facility Address: 12810 EDGEMERE BLVD
    EL PASO, TX
    ZIP 79938
  • Facility Phone: 915 504-6955
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: MAURO PROVENCIO
  • NPI Number: 1336694397
  • Taxonomy: 171WH0202X - Contractor

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CLIA Record

Field Name Field Value
CLIA Number 45D2047058
LAB Type Physician Office
Facility Name SUN CITY SPORTS MEDICINE AND FAMILY CLINIC,PA
Street 12810 EDGEMERE BLVD
City EL PASO
State TX
ZIP 79938
Phone 915 504-6955
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/18/2024
Certificate Expiration Date 9/17/2026
Facility Type Physician Office
Lab Director MAURO PROVENCIO

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