Provider First Line Business Practice Location Address:
10305 NE HALSEY ST
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:
97220-3954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-0048
Provider Business Practice Location Address Fax Number:
503-256-4041
Provider Enumeration Date:
01/28/2011