Provider First Line Business Practice Location Address:
9221 SW BARBUR BLVD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-5441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-546-2511
Provider Business Practice Location Address Fax Number:
503-546-2510
Provider Enumeration Date:
06/21/2005