Provider First Line Business Practice Location Address:
7404 N INTERSTATE AVE
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:
97217-5528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-286-6784
Provider Business Practice Location Address Fax Number:
503-286-6792
Provider Enumeration Date:
02/22/2012