Provider First Line Business Practice Location Address:
3181 SAM JACKSON PARK ROAD, MAIL CODE L457
Provider Second Line Business Practice Location Address:
OREGON HEALTH & SCIENCE UNIVERSITY, DIV OF ID
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-3098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-0591
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2011