Provider First Line Business Practice Location Address:
12550 SE 93RD AVE
Provider Second Line Business Practice Location Address:
STE 265
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-8796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-659-9155
Provider Business Practice Location Address Fax Number:
503-659-7336
Provider Enumeration Date:
11/16/2005