Provider First Line Business Practice Location Address:
6336 SE MILWAUKIE AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97202-5419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-230-4833
Provider Business Practice Location Address Fax Number:
503-235-4250
Provider Enumeration Date:
12/05/2005