Provider First Line Business Practice Location Address:
7707 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:
97219-2458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-452-8002
Provider Business Practice Location Address Fax Number:
503-452-0084
Provider Enumeration Date:
10/27/2009