Provider First Line Business Practice Location Address:
52751 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:
97056-3029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-543-5026
Provider Business Practice Location Address Fax Number:
503-543-2670
Provider Enumeration Date:
05/27/2006