Provider First Line Business Practice Location Address:
9255 NE HALSEY STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-726-3792
Provider Business Practice Location Address Fax Number:
503-726-3793
Provider Enumeration Date:
06/15/2011