Provider First Line Business Practice Location Address:
527 SE BASELINE ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97123-4149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-648-6054
Provider Business Practice Location Address Fax Number:
503-648-6099
Provider Enumeration Date:
07/27/2006