Provider First Line Business Practice Location Address:
2730 SW MOODY 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:
97201-5042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-418-1669
Provider Business Practice Location Address Fax Number:
503-494-8486
Provider Enumeration Date:
08/26/2005