38D0898204 CLIA NUMBER - PROVIDENCE MEDICAL GROUP CLACKAMAS

Laboratory Demographics

  • CLIA Code: 38D0898204
  • Facility Name: PROVIDENCE MEDICAL GROUP CLACKAMAS
  • Facility Address: 9290 SE SUNNYBROOK BLVD SUITE 120
    CLACKAMAS, OR
    ZIP 97015
  • Facility Phone: 503 215-2110
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: BRENT HOFFMAN
  • NPI Number: 1033804091
  • Taxonomy: 2084P0802X - Psychiatry & Neurology

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CLIA Record

Field Name Field Value
CLIA Number 38D0898204
LAB Type Physician Office
Facility Name PROVIDENCE MEDICAL GROUP CLACKAMAS
Street 9290 SE SUNNYBROOK BLVD SUITE 120
City CLACKAMAS
State OR
ZIP 97015
Phone 503 215-2110
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/1/2025
Certificate Expiration Date 7/31/2027
Facility Type Physician Office
Lab Director BRENT HOFFMAN

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