Provider First Line Business Practice Location Address:
7822 SW CAPITOL HWY STE 5
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:
97219-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-422-7987
Provider Business Practice Location Address Fax Number:
503-914-1561
Provider Enumeration Date:
04/20/2011