Provider First Line Business Practice Location Address:
6620 NE 79TH CT
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97218-2862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-257-3373
Provider Business Practice Location Address Fax Number:
503-408-9041
Provider Enumeration Date:
10/25/2006