Organization
PHYSICIAN ON DUTY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SANDRA L JOLLY (BILLING MANAGER)
(503) 726-4685
Entity
Organization
Contact information
Practice address
14805 SW BLANTON ST., BEAVERTON, OR 97007
(503) 957-9632
Mailing address
14805 SW BLANTON ST., BEAVERTON, OR 97007
(503) 957-9632
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
—
—
Other
Enumeration date
11/11/2008
Last updated
11/11/2008
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