Provider First Line Business Practice Location Address:
3822 SE POWELL 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:
97202-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-238-4540
Provider Business Practice Location Address Fax Number:
503-238-0323
Provider Enumeration Date:
12/19/2006