Provider First Line Business Practice Location Address:
7301 N ALTA AVE
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:
97203-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-286-0023
Provider Business Practice Location Address Fax Number:
503-286-8335
Provider Enumeration Date:
07/12/2005