Provider First Line Business Practice Location Address:
6003 SE CARLTON 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:
97206-6721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-774-2438
Provider Business Practice Location Address Fax Number:
503-772-0313
Provider Enumeration Date:
01/28/2008