38D0973869 CLIA NUMBER - PROVIDENCE ELDERPLACE

Laboratory Demographics

CLIA Code: 38D0973869
Facility Name: PROVIDENCE ELDERPLACE
Facility Address: 13007 NE GLISAN ST
PORTLAND, OR
ZIP 97230
Facility Phone: 503 215-6556
Facility Type: Other - ELDERPLACE HEALTH AND SOC
Facility Type: Waiver
Lab Director: PAMELA BOSA
NPI Number: 1023738424
Taxonomy: 251T00000X - Program of All-Inclusive Care for the Elderly (PACE) Provider Organization

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CLIA Record

Field Name	Field Value
CLIA Number	38D0973869
LAB Type	Other - ELDERPLACE HEALTH AND SOC
Facility Name	PROVIDENCE ELDERPLACE
Street	13007 NE GLISAN ST
City	PORTLAND
State	OR
ZIP	97230
Phone	503 215-6556
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	5/22/2024
Certificate Expiration Date	5/21/2026
Facility Type	Other - ELDERPLACE HEALTH AND SOC
Lab Director	PAMELA BOSA

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