Provider First Line Business Practice Location Address:
12612 SE STARK 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:
97233-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-257-6393
Provider Business Practice Location Address Fax Number:
503-257-8785
Provider Enumeration Date:
09/26/2006