Provider First Line Business Practice Location Address:
3133 NE PRESCOTT 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:
97211-7167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-5666
Provider Business Practice Location Address Fax Number:
503-432-8668
Provider Enumeration Date:
03/02/2016