Provider First Line Business Practice Location Address:
2002 SE 50TH AVE
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:
97215-3823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-640-4012
Provider Business Practice Location Address Fax Number:
503-239-9192
Provider Enumeration Date:
06/23/2006