Provider First Line Business Practice Location Address:
2824 NE WASCO 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:
97232-1772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-5678
Provider Business Practice Location Address Fax Number:
503-284-5556
Provider Enumeration Date:
07/31/2006