Provider First Line Business Practice Location Address:
9370 SW GREENBURG RD GRANT NORTH
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-245-6441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007