Organization
YE OLDE COBBLER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD A FILONCZUK (OWNER/ OPERATOR)
(503) 682-0354
Entity
Organization
Contact information
Practice address
30605 SW MAGNOLIA AVE, WILSONVILLE, OR 97070-6757
(503) 682-0354
Mailing address
PO BOX 482, WILSONVILLE, OR 97070-0482
(503) 682-0354
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
160655
—
OR
Enumeration date
07/27/2007
Last updated
01/17/2008
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