| NPI | 1417975152 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TINA BANCKE Credentialing Coordinator 503-905-4361 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: OR MD22411) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2012-02-21 |