Provider First Line Business Practice Location Address:
51385 SW OLD PORTLAND RD STE B
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:
97056-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-781-6634
Provider Business Practice Location Address Fax Number:
971-288-1776
Provider Enumeration Date:
12/29/2025