Provider First Line Business Practice Location Address:
6230 NE HALSEY 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:
97213-4718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-236-8697
Provider Business Practice Location Address Fax Number:
503-236-1525
Provider Enumeration Date:
03/30/2007