Provider First Line Business Practice Location Address:
3620 NE 122ND AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-4100
Provider Business Practice Location Address Fax Number:
503-252-3390
Provider Enumeration Date:
04/17/2008