Provider First Line Business Practice Location Address:
8026 N EDISON ST
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:
97203-4908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-384-4553
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2012