Provider First Line Business Practice Location Address:
10802 SE WASHINGTON ST
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:
97216-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-699-1911
Provider Business Practice Location Address Fax Number:
503-699-1912
Provider Enumeration Date:
02/28/2011