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General NPI Number Information
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NPI Number | 1225066194
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Entity Type | Organization
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Legal Business Name | MAPLE STREET CLINIC, PC
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Dates
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Enumeration Date | 06/29/2006
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Last Update Date | 01/10/2013
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Provider Practice Location Address
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Address Line | 1825 MAPLE ST
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City | FOREST GROVE
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State | OR
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Zip | 97116-1939
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Country | US
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Telephone | 503-357-2136
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Fax | 503-359-5479
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Provider Business Mailing Address
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Address Line | 1825 MAPLE ST
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City | FOREST GROVE
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State | OR
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Zip | 97116-1939
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Country | US
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Telephone | 503-357-2136
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Fax | 503-359-5479
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Authorized Official
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Title or Position | CLINIC ADMINISTRATOR
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Name | MR. JOHN DAHLQUIST
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Credential |
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Telephone | 503-357-2136
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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