Provider First Line Business Practice Location Address:
3181 SW SAM JACKSON PARK RD
Provider Second Line Business Practice Location Address:
MAIL CODE DC7P
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-418-5775
Provider Business Practice Location Address Fax Number:
503-418-5774
Provider Enumeration Date:
02/15/2006