Provider First Line Business Practice Location Address:
5015 SE HAWTHORNE BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97215-3255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-715-7982
Provider Business Practice Location Address Fax Number:
503-242-1146
Provider Enumeration Date:
12/26/2006