Provider First Line Business Practice Location Address:
11300 NE HALSEY ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97220-2096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-257-9881
Provider Business Practice Location Address Fax Number:
503-257-8964
Provider Enumeration Date:
03/20/2006