Provider First Line Business Practice Location Address:
2403 SE MONROE ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-7646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-654-5995
Provider Business Practice Location Address Fax Number:
503-653-0465
Provider Enumeration Date:
09/12/2005