Provider First Line Business Practice Location Address:
4437 SE 39TH AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97202-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-774-3585
Provider Business Practice Location Address Fax Number:
503-774-3602
Provider Enumeration Date:
08/06/2008