Provider First Line Business Practice Location Address:
15577 SW 116TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KING CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97224-2653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-968-6445
Provider Business Practice Location Address Fax Number:
503-968-8968
Provider Enumeration Date:
01/21/2015