Provider First Line Business Practice Location Address:
51385 SW OLD PORTLAND RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SCAPPOOSE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97056-4061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-543-7768
Provider Business Practice Location Address Fax Number:
503-543-7772
Provider Enumeration Date:
11/14/2006