Provider First Line Business Practice Location Address:
7931 NE HALSEY ST
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-6755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-216-5931
Provider Business Practice Location Address Fax Number:
503-252-1214
Provider Enumeration Date:
07/04/2013