Provider First Line Business Practice Location Address:
10200 SW EASTRIDGE ST
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-207-2066
Provider Business Practice Location Address Fax Number:
503-548-4981
Provider Enumeration Date:
06/27/2006