Provider First Line Business Practice Location Address:
620 SOUTHEAST 160TH AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-9527
Provider Business Practice Location Address Fax Number:
503-252-4516
Provider Enumeration Date:
09/21/2006