Provider First Line Business Practice Location Address:
6840 S MACADAM AVE
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:
97219-2314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-936-8640
Provider Business Practice Location Address Fax Number:
503-907-7779
Provider Enumeration Date:
06/15/2006