Provider First Line Business Practice Location Address:
1120 SW 3RD AVE
Provider Second Line Business Practice Location Address:
DENTENTION CENTER
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97204-2801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-988-3976
Provider Business Practice Location Address Fax Number:
503-988-3975
Provider Enumeration Date:
04/30/2009