Provider First Line Business Practice Location Address:
2730 SW MOODEY AVE
Provider Second Line Business Practice Location Address:
CLSB-5N034
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-8949
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2008