Provider First Line Business Practice Location Address:
6227 SE POWELL BLVD
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:
97206-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-777-1332
Provider Business Practice Location Address Fax Number:
360-777-9990
Provider Enumeration Date:
06/15/2005