Provider First Line Business Practice Location Address:
10360 NE WASCO 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:
97220-3927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-8125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2005