Provider First Line Business Practice Location Address:
51579 COLUMBIA RIVER HWY
Provider Second Line Business Practice Location Address:
SUITE F
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:
971-285-6411
Provider Business Practice Location Address Fax Number:
503-543-3550
Provider Enumeration Date:
02/28/2011