Provider First Line Business Practice Location Address:
6339 SW CAPITOL HWY
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:
97239-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-246-1881
Provider Business Practice Location Address Fax Number:
503-246-1557
Provider Enumeration Date:
12/22/2005