Provider First Line Business Practice Location Address:
900 HIGHWAY 22 NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDANHA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97350-9507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-428-2280
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2025