Provider First Line Business Practice Location Address:
1414 NW 53RD DRIVE
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:
97210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-236-2999
Provider Business Practice Location Address Fax Number:
503-236-4334
Provider Enumeration Date:
03/28/2007