Provider First Line Business Practice Location Address:
51377 OLD PORTLAND ROAD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SCAPPOOSE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-418-4222
Provider Business Practice Location Address Fax Number:
503-418-4223
Provider Enumeration Date:
09/20/2006