Provider First Line Business Practice Location Address:
4004 SW KELLY 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:
97239-4389
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-223-5152
Provider Business Practice Location Address Fax Number:
503-224-3454
Provider Enumeration Date:
11/03/2005