Provider First Line Business Practice Location Address:
10355 NW GLENCOE RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NORTH PLAINS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97133-8244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-647-9944
Provider Business Practice Location Address Fax Number:
503-447-5011
Provider Enumeration Date:
07/09/2005