Organization
PORTLAND TISSUE PROCESSING LABORATORY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JANE PALOMO ROBERTSON (BUSINESS MANAGER)
(503) 287-7721
Entity
Organization
Contact information
Practice address
5012 NE 42ND AVE, PORTLAND, OR 97218-1504
(503) 287-7721
(503) 287-7728
Mailing address
5012 NE 42ND AVE, PORTLAND, OR 97218-1504
(503) 287-7721
(503) 287-7728
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
38D1063205
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001135000
REGENCE BCBS
OR
01
—
125786
DEPT. OF LABOR & INDUSTRY
WA
05
—
131313
—
OR
01
—
300899101
REGENCE HMO OREGON
OR
01
—
410930
PROVIDENCE HEALTH PLANS
OH
01
—
7108244
WA - DSHS
WA
01
—
KE4600
HEALTH NET
OR
Enumeration date
03/13/2007
Last updated
02/29/2012
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