Provider First Line Business Practice Location Address:
1111 NE 99TH AVENUE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-963-2707
Provider Business Practice Location Address Fax Number:
503-963-2802
Provider Enumeration Date:
07/26/2006