Provider First Line Business Practice Location Address:
543 3RD ST
Provider Second Line Business Practice Location Address:
SUITE C-12
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97034-3067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-697-3484
Provider Business Practice Location Address Fax Number:
503-697-0704
Provider Enumeration Date:
05/23/2007