Provider First Line Business Practice Location Address:
23500 NE SANDY BLVD
Provider Second Line Business Practice Location Address:
LOCATED INSIDE WALMART
Provider Business Practice Location Address City Name:
WOOD VILLAGE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97060-9653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-667-8869
Provider Business Practice Location Address Fax Number:
503-667-7598
Provider Enumeration Date:
09/17/2006