38D0863204 CLIA NUMBER - PROVIDENCE MEDICAL GROUP - THE PLAZA CLINIC

Laboratory Demographics

  • CLIA Code: 38D0863204
  • Facility Name: PROVIDENCE MEDICAL GROUP - THE PLAZA CLINIC
  • Facility Address: 5050 NE HOYT STREET SUITE 454
    PORTLAND, OR
    ZIP 97213
  • Facility Phone: 503 215-6405
  • Facility Type: Mobile Laboratory
  • Facility Type: Waiver
  • Lab Director: KIMBERLY J. HERDER
  • NPI Number: 1447371117
  • Taxonomy: 207R00000X - Internal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 38D0863204
LAB Type Mobile Laboratory
Facility Name PROVIDENCE MEDICAL GROUP - THE PLAZA CLINIC
Street 5050 NE HOYT STREET SUITE 454
City PORTLAND
State OR
ZIP 97213
Phone 503 215-6405
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/22/2024
Certificate Expiration Date 8/21/2026
Facility Type Mobile Laboratory
Lab Director KIMBERLY J. HERDER

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