Provider First Line Business Practice Location Address:
9512 NE SACRAMENTO 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:
97220-4340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-255-6402
Provider Business Practice Location Address Fax Number:
503-255-6402
Provider Enumeration Date:
04/17/2007