Provider First Line Business Practice Location Address:
12724 SE STARK STREET, BUILDING H
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-253-3131
Provider Business Practice Location Address Fax Number:
503-253-2895
Provider Enumeration Date:
01/24/2007