Provider First Line Business Practice Location Address:
12161 SE JOHANSEN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-7226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-586-9800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2025