Provider First Line Business Practice Location Address:
16330 SE STARK STREET
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:
97233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-5567
Provider Business Practice Location Address Fax Number:
503-252-1995
Provider Enumeration Date:
09/13/2006