Provider First Line Business Practice Location Address:
6605 SE LAKE RD RM 144A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-2161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-557-3051
Provider Business Practice Location Address Fax Number:
503-974-1205
Provider Enumeration Date:
01/27/2023