Provider First Line Business Practice Location Address:
51579 COLUMBIA RIVER HWY STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCAPPOOSE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97056-8411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-352-1601
Provider Business Practice Location Address Fax Number:
503-543-6040
Provider Enumeration Date:
04/23/2012