Provider First Line Business Practice Location Address:
6124 SE MILWAUKIE AVE STE C
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:
97202-5347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-807-7180
Provider Business Practice Location Address Fax Number:
503-236-2700
Provider Enumeration Date:
01/23/2009