Provider First Line Business Practice Location Address:
11786 SW BARNES RD
Provider Second Line Business Practice Location Address:
STE 320
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-641-3550
Provider Business Practice Location Address Fax Number:
503-574-2078
Provider Enumeration Date:
09/27/2005