Provider First Line Business Practice Location Address:
6422 SE MILWAUKIE 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:
97202-5518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-235-9238
Provider Business Practice Location Address Fax Number:
503-235-4226
Provider Enumeration Date:
10/17/2005