Organization
MAPLE STREET CLINIC, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHN DAHLQUIST (CLINIC ADMINISTRATOR)
(503) 357-2136
Entity
Organization
Contact information
Practice address
1825 MAPLE ST, FOREST GROVE, OR 97116-1939
(503) 357-2136
(503) 359-5479
Mailing address
1825 MAPLE ST, FOREST GROVE, OR 97116-1939
(503) 357-2136
(503) 359-5479
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R0000WCBCC
MEDICARE PTIN
OR
Enumeration date
06/29/2006
Last updated
01/10/2013
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