Provider First Line Business Practice Location Address:
51577 COLUMBIA RIVER HWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SCAPPOOSE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97056-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-396-4807
Provider Business Practice Location Address Fax Number:
503-397-5373
Provider Enumeration Date:
01/22/2016