Provider First Line Business Practice Location Address:
41535 OLD HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97103-8640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-458-5993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2025