Provider First Line Business Practice Location Address:
1212 SE POWELL BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97202-2460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-556-3443
Provider Business Practice Location Address Fax Number:
954-963-7169
Provider Enumeration Date:
12/29/2008