05D1068686 CLIA NUMBER - PROVIDENT PRIMARY CARE INC

Laboratory Demographics

CLIA Number: 05D1068686

Facility Name: PROVIDENT PRIMARY CARE INC

Facility Address:
450 E YOSEMITE AVENUE, SUITE A
MERCED, CA
ZIP 95340
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Facility Phone Number: 209 725-1112

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1154785517

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D1068686
LAB Type	Physician Office
Facility Name	PROVIDENT PRIMARY CARE INC
Street	450 E YOSEMITE AVENUE, SUITE A
City	MERCED
State	CA
ZIP	95340
Phone	209 725-1112
CertificateType	4
CertificateEffectiveDate	5/18/2023
CertificateExpirationDate	5/17/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024