Provider First Line Business Practice Location Address:
4310 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:
97217-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-395-4212
Provider Business Practice Location Address Fax Number:
503-388-3861
Provider Enumeration Date:
02/22/2007