Provider First Line Business Practice Location Address:
1410 SW JEFFERSON 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:
97201-2548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-887-2209
Provider Business Practice Location Address Fax Number:
888-894-1774
Provider Enumeration Date:
06/26/2006