Provider First Line Business Practice Location Address:
16506 SE SLATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAMASCUS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97089-9123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-522-0485
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2026