38D0924876 CLIA NUMBER - PROVIDENCE MEDICAL GROUP SOUTHEAST

Laboratory Demographics

CLIA Number: 38D0924876

Facility Name: PROVIDENCE MEDICAL GROUP SOUTHEAST

Facility Address:
4104 SE 82ND AVE SUITE 250
PORTLAND, OR
ZIP 97266
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Facility Phone Number: 503 215-9850

Facility Type: Physician Office

Certificate Type: Microscopy

NPI Number: 1679678866

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	38D0924876
LAB Type	Physician Office
Facility Name	PROVIDENCE MEDICAL GROUP SOUTHEAST
Street	4104 SE 82ND AVE SUITE 250
City	PORTLAND
State	OR
ZIP	97266
Phone	503 215-9850
CertificateType	3
CertificateEffectiveDate	10/1/2023
CertificateExpirationDate	9/30/2025
FacilityType	PPMP

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