Provider First Line Business Practice Location Address:
9932 NE HALSEY 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:
97220-4474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-491-1723
Provider Business Practice Location Address Fax Number:
503-489-0706
Provider Enumeration Date:
05/27/2005