Provider First Line Business Practice Location Address:
6116 NE MLK BLVD
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:
97211-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-0689
Provider Business Practice Location Address Fax Number:
503-282-0809
Provider Enumeration Date:
09/10/2009