Provider First Line Business Practice Location Address:
12901 SE 97TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-652-0067
Provider Business Practice Location Address Fax Number:
503-652-0068
Provider Enumeration Date:
06/21/2005