Provider Demographics
NPI:1154454718
Name:PORTLAND TISSUE PROCESSING LABORATORY, INC.
Entity Type:Organization
Organization Name:PORTLAND TISSUE PROCESSING LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:PALOMO
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-287-7721
Mailing Address - Street 1:5012 NE 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-1504
Mailing Address - Country:US
Mailing Address - Phone:503-287-7721
Mailing Address - Fax:503-287-7728
Practice Address - Street 1:5012 NE 42ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-1504
Practice Address - Country:US
Practice Address - Phone:503-287-7721
Practice Address - Fax:503-287-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D1063205291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR300899101OtherREGENCE HMO OREGON
WA7108244OtherWA - DSHS
ORKE4600OtherHEALTH NET
WA125786OtherDEPT. OF LABOR & INDUSTRY
OR131313Medicaid
OH410930OtherPROVIDENCE HEALTH PLANS
OR001135000OtherREGENCE BCBS
OR131313Medicaid
OR131313Medicaid
OR300899101OtherREGENCE HMO OREGON