Provider First Line Business Practice Location Address:
2824 SW SAM JACKSON PARK RD
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:
97201-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-243-1974
Provider Business Practice Location Address Fax Number:
503-243-2606
Provider Enumeration Date:
04/19/2012