Organization
LAKE GROVE ENT PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHERYL LEE KRUSE (CLINIC MANAGER)
(503) 699-0370
Entity
Organization
Contact information
Practice address
17704 JEAN WAY, STE 101, LAKE OSWEGO, OR 97035-5497
(503) 699-0370
(971) 236-9099
Mailing address
17704 JEAN WAY, STE 101, LAKE OSWEGO, OR 97035-5497
(503) 699-0370
(971) 236-9099
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005809
—
OR
Enumeration date
08/03/2005
Last updated
04/04/2022
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