Provider First Line Business Practice Location Address:
9833 N PORTSMOUTH 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:
97203-1940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-286-1015
Provider Business Practice Location Address Fax Number:
503-286-2642
Provider Enumeration Date:
10/01/2013