Provider First Line Business Practice Location Address:
9855 SW CAPITOL HWY
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:
97219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-245-4690
Provider Business Practice Location Address Fax Number:
503-245-4708
Provider Enumeration Date:
11/15/2012