Provider First Line Business Practice Location Address:
1224 SW UPLAND DR
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:
97221-2654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-295-4488
Provider Business Practice Location Address Fax Number:
503-295-4488
Provider Enumeration Date:
11/07/2005