Provider First Line Business Practice Location Address:
13112 NE HALSEY 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:
97230-2350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-3952
Provider Business Practice Location Address Fax Number:
503-252-3052
Provider Enumeration Date:
10/08/2019