Graduated: 2016
NPI: 1346799590
Practice Locations (2)
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
1160 WALLACE RD NW
SALEM, OR 973043116
8008132000
ICCO LLC
2902 TOM TENNANT DR
WOODBURN, OR 970712828
5416407625
Source: CMS National Downloadable File, September 2026.