Provider First Line Business Practice Location Address:
173A NE 102ND AVE
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:
97220-4176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-5100
Provider Business Practice Location Address Fax Number:
503-253-8086
Provider Enumeration Date:
03/15/2007