Provider First Line Business Practice Location Address:
51579 COLUMBIA RIVER HWY
Provider Second Line Business Practice Location Address:
STE 'I'
Provider Business Practice Location Address City Name:
SCAPPOOSE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97056-8411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-543-6164
Provider Business Practice Location Address Fax Number:
503-543-6040
Provider Enumeration Date:
05/01/2006