Provider First Line Business Practice Location Address:
555 SW OAK ST
Provider Second Line Business Practice Location Address:
WESTSIDE ATHLETIC CLUB
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97204-1752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-208-4325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2009