Provider First Line Business Practice Location Address:
12037 NE MARX 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:
97220-9013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-408-8378
Provider Business Practice Location Address Fax Number:
503-408-8389
Provider Enumeration Date:
06/30/2006