Provider First Line Business Practice Location Address:
5232 N INTERSTATE AVENUE
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:
97217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-575-9402
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2009