38D0965604 CLIA NUMBER - PROVIDENCE MEDICAL GROUP GRESHAM

Laboratory Demographics

  • CLIA Code: 38D0965604
  • Facility Name: PROVIDENCE MEDICAL GROUP GRESHAM
  • Facility Address: 440 NW DIVISION ST
    GRESHAM, OR
    ZIP 97030
  • Facility Phone: 503 215-9500
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: JANET PATIN
  • NPI Number: 1053419218
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 38D0965604
LAB Type Physician Office
Facility Name PROVIDENCE MEDICAL GROUP GRESHAM
Street 440 NW DIVISION ST
City GRESHAM
State OR
ZIP 97030
Phone 503 215-9500
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/21/2024
Certificate Expiration Date 4/20/2026
Facility Type Physician Office
Lab Director JANET PATIN

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