Provider Demographics
NPI:1225066194
Name:MAPLE STREET CLINIC, PC
Entity Type:Organization
Organization Name:MAPLE STREET CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-357-2136
Mailing Address - Street 1:1825 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1939
Mailing Address - Country:US
Mailing Address - Phone:503-357-2136
Mailing Address - Fax:503-359-5479
Practice Address - Street 1:1825 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1939
Practice Address - Country:US
Practice Address - Phone:503-357-2136
Practice Address - Fax:503-359-5479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCBCCOtherMEDICARE PTIN