Individual
ALISE FAIRCLOTH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1921 SW 144TH AVE, BEAVERTON, OR 97005-2356
(503) 704-6982
Mailing address
1921 SW 144TH AVE, BEAVERTON, OR 97005-2356
(503) 704-6982
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
21439
OR
Other
Enumeration date
08/17/2015
Last updated
08/17/2015
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