Provider First Line Business Practice Location Address:
7821 SE STARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97215-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-9926
Provider Business Practice Location Address Fax Number:
503-282-9887
Provider Enumeration Date:
03/13/2009