Provider First Line Business Practice Location Address:
9204 SE MITCHELL 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:
97266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-777-6746
Provider Business Practice Location Address Fax Number:
503-777-0023
Provider Enumeration Date:
08/02/2006