Provider First Line Business Practice Location Address:
6801 NE CORNFOOT ROAD
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:
97218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-335-4557
Provider Business Practice Location Address Fax Number:
503-335-5609
Provider Enumeration Date:
05/05/2009