Provider First Line Business Practice Location Address:
9732 SE WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE H
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97216-8405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-255-8996
Provider Business Practice Location Address Fax Number:
503-255-0778
Provider Enumeration Date:
06/20/2005