Provider First Line Business Practice Location Address:
12845 SE 93RD AVE
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:
97015-5735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-794-1900
Provider Business Practice Location Address Fax Number:
503-794-2778
Provider Enumeration Date:
11/01/2005