Provider First Line Business Practice Location Address:
9495 SW LOCUST ST STE A&E
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:
97223-6683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-471-0500
Provider Business Practice Location Address Fax Number:
503-471-0504
Provider Enumeration Date:
07/21/2005