19D2233243 CLIA NUMBER - PROVIDENCE PRIMARY CARE, LLC

Laboratory Demographics

  • CLIA Code: 19D2233243
  • Facility Name: PROVIDENCE PRIMARY CARE, LLC
  • Facility Address: 1000 CHINABERRY DRIVE, SUITE 1002
    BOSSIER CITY, LA
    ZIP 71111
  • Facility Phone: 318 562-3911
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: LINDSEY M. FORTENBERRY
  • NPI Number: 1386238525
  • Taxonomy: 363LP2300X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 19D2233243
LAB Type Practitioner Other
Facility Name PROVIDENCE PRIMARY CARE, LLC
Street 1000 CHINABERRY DRIVE, SUITE 1002
City BOSSIER CITY
State LA
ZIP 71111
Phone 318 562-3911
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/20/2025
Certificate Expiration Date 8/19/2027
Facility Type Practitioner Other
Lab Director LINDSEY M. FORTENBERRY

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