Provider First Line Business Practice Location Address:
3181 SW SAM JACKSON PARK RD
Provider Second Line Business Practice Location Address:
MAIL CODE: OP11
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-7593
Provider Business Practice Location Address Fax Number:
503-346-8081
Provider Enumeration Date:
06/15/2006