Provider First Line Business Practice Location Address:
0615 SW PALATINE HILL RD
Provider Second Line Business Practice Location Address:
LEWIS AND CLARK COLLEGE MSC 135
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-7879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-768-7160
Provider Business Practice Location Address Fax Number:
503-768-7115
Provider Enumeration Date:
12/22/2006