Provider First Line Business Practice Location Address:
12672 SE STARK ST
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:
97233-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-254-2652
Provider Business Practice Location Address Fax Number:
503-254-2814
Provider Enumeration Date:
03/06/2007