38D0894595 CLIA NUMBER - PROVIDENCE MEDICAL GROUP MARY'S WOODS

Laboratory Demographics

CLIA Number: 38D0894595

Facility Name: PROVIDENCE MEDICAL GROUP MARY'S WOODS

Facility Address:
17550 PROVOST ST, SUITE 201
LAKE OSWEGO, OR
ZIP 97034
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Facility Phone Number: 503 872-2440

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1568793313

Taxonomy: 261Q00000X - Clinic/Center
A facility or distinct part of one used for the diagnosis and treatment of outpatients. Clinic/Center is irregularly defined, sometimes being limited to organizations serving specialized treatment requirements or distinct patient/client groups (e.g., radiology, poor, and public health).

CLIA Record

Field Name	Field Value
CLIA Number	38D0894595
LAB Type	Physician Office
Facility Name	PROVIDENCE MEDICAL GROUP MARY'S WOODS
Street	17550 PROVOST ST, SUITE 201
City	LAKE OSWEGO
State	OR
ZIP	97034
Phone	503 872-2440
CertificateType	4
CertificateEffectiveDate	6/1/2023
CertificateExpirationDate	5/31/2025
FacilityType	Waiver

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