05D2229898 CLIA NUMBER - PROVIDENCE MEDICAL FOUNDATION

Laboratory Demographics

  • CLIA Code: 05D2229898
  • Facility Name: PROVIDENCE MEDICAL FOUNDATION
  • Facility Address: 500 DOYLE PARK DRIVE, SUITE G04
    SANTA ROSA, CA
    ZIP 95405
  • Facility Phone: 707 576-7100
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: TOMAS VASILIAUSKAS
  • NPI Number: 1740584473
  • Taxonomy: 207R00000X - Internal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 05D2229898
LAB Type Physician Office
Facility Name PROVIDENCE MEDICAL FOUNDATION
Street 500 DOYLE PARK DRIVE, SUITE G04
City SANTA ROSA
State CA
ZIP 95405
Phone 707 576-7100
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/18/2024
Certificate Expiration Date 4/17/2026
Facility Type Physician Office
Lab Director TOMAS VASILIAUSKAS

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