Provider First Line Business Practice Location Address:
8401 NE HALSEY STREET
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-539-9753
Provider Business Practice Location Address Fax Number:
503-254-5090
Provider Enumeration Date:
02/01/2007