Provider First Line Business Practice Location Address:
1100 NE 178TH 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:
97230-6322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-669-7472
Provider Business Practice Location Address Fax Number:
503-669-7472
Provider Enumeration Date:
12/18/2007