Provider First Line Business Practice Location Address:
3839 NE TILLAMOOK 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:
97212-5338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-288-5891
Provider Business Practice Location Address Fax Number:
503-288-1525
Provider Enumeration Date:
09/07/2006