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50D2195740 CLIA NUMBER - PROVIDENCE ABUSE INTERVENTION CENTER

Laboratory Demographics

CLIA Number: 50D2195740

Facility Name: PROVIDENCE ABUSE INTERVENTION CENTER

Facility Address:
3020 WILLAMETTE DR NE
LACEY, WA
ZIP 98516
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Facility Phone Number: 360 493-7469

Facility Type: Other - CLINIC

Certificate Type: Waiver
NPI Number: 1063611408

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 50D2195740
LAB Type Other - CLINIC
Facility Name PROVIDENCE ABUSE INTERVENTION CENTER
Street 3020 WILLAMETTE DR NE
City LACEY
State WA
ZIP 98516
Phone 360 493-7469
CertificateType 4
CertificateEffectiveDate 10/12/2020
CertificateExpirationDate 4/4/2028
FacilityType Waiver

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