Provider First Line Business Practice Location Address:
51669 SOUTH COLUMBIA RIVER HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
SCAPPOOSE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97056-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-543-8605
Provider Business Practice Location Address Fax Number:
503-210-8166
Provider Enumeration Date:
09/14/2005