Provider First Line Business Practice Location Address:
1890 NE 162ND 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:
97230-5642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-644-1110
Provider Business Practice Location Address Fax Number:
503-641-6431
Provider Enumeration Date:
12/30/2008