Provider First Line Business Practice Location Address:
1121 NE 2ND AVE
Provider Second Line Business Practice Location Address:
OREGON STATE HOSPITAL PORTLAND
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-731-8680
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2006