Provider First Line Business Practice Location Address:
8106 NE WASCO ST
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:
97213-6737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-255-8258
Provider Business Practice Location Address Fax Number:
503-252-1668
Provider Enumeration Date:
04/08/2013