Provider First Line Business Practice Location Address:
10772 SE 99TH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAPPY VALLEY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97086-7269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-765-9016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2026