Provider First Line Business Practice Location Address:
2448 SE 89TH AVE
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:
97216-2052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-788-6483
Provider Business Practice Location Address Fax Number:
503-772-7914
Provider Enumeration Date:
06/07/2006