Provider First Line Business Practice Location Address:
1433 SE 122ND 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:
97233-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-3238
Provider Business Practice Location Address Fax Number:
503-253-8654
Provider Enumeration Date:
06/29/2009