Provider First Line Business Practice Location Address:
4104 SE 82ND AVENUE
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:
97266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-771-4324
Provider Business Practice Location Address Fax Number:
503-771-4458
Provider Enumeration Date:
12/12/2006