Provider First Line Business Practice Location Address:
5216 SE 32ND 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:
97202-4310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-234-7299
Provider Business Practice Location Address Fax Number:
503-234-9639
Provider Enumeration Date:
11/29/2006