Provider First Line Business Practice Location Address:
3181 SW SAM JACKSON PARK RD
Provider Second Line Business Practice Location Address:
MAILING CODE L-466
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-0577
Provider Business Practice Location Address Fax Number:
503-494-2391
Provider Enumeration Date:
04/10/2009