Provider First Line Business Practice Location Address:
5717 NE 138TH 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:
97230-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-261-7571
Provider Business Practice Location Address Fax Number:
503-261-7537
Provider Enumeration Date:
09/30/2015