Provider First Line Business Practice Location Address:
1244 SE 122ND AVE.
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:
97233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-8338
Provider Business Practice Location Address Fax Number:
503-256-6288
Provider Enumeration Date:
10/04/2006