Provider First Line Business Practice Location Address:
11786 SW BARNES RD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-644-4425
Provider Business Practice Location Address Fax Number:
503-644-4314
Provider Enumeration Date:
07/13/2005