Provider First Line Business Practice Location Address:
7346 NE SANDY BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-5758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-287-7899
Provider Business Practice Location Address Fax Number:
503-287-7933
Provider Enumeration Date:
10/13/2005