Provider First Line Business Practice Location Address:
5025 SE 28TH 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:
97202-4445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-238-4418
Provider Business Practice Location Address Fax Number:
503-238-0360
Provider Enumeration Date:
09/15/2006