Provider First Line Business Practice Location Address:
17316 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:
97230-6026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-257-6623
Provider Business Practice Location Address Fax Number:
503-257-6624
Provider Enumeration Date:
05/03/2006