Provider First Line Business Practice Location Address:
16756 SE 82ND DR
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:
97015-8589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-606-6512
Provider Business Practice Location Address Fax Number:
503-557-8672
Provider Enumeration Date:
10/07/2025