Provider First Line Business Practice Location Address:
10502 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:
97220-3948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-2467
Provider Business Practice Location Address Fax Number:
503-252-0670
Provider Enumeration Date:
09/20/2005