Provider First Line Business Practice Location Address:
51701 COLUMBIA RIVER HWY
Provider Second Line Business Practice Location Address:
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:
503-987-1378
Provider Business Practice Location Address Fax Number:
503-467-5592
Provider Enumeration Date:
10/25/2006