Provider First Line Business Practice Location Address:
3181 SSAM JACKSON PARK RD
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:
97207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-220-8262
Provider Business Practice Location Address Fax Number:
360-737-1419
Provider Enumeration Date:
10/02/2006