Provider First Line Business Practice Location Address:
5625 SE 48TH 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:
97206-5620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-788-5343
Provider Business Practice Location Address Fax Number:
503-788-1116
Provider Enumeration Date:
09/20/2006