Provider First Line Business Practice Location Address:
8113 SE 13TH 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:
97202-6607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-234-5653
Provider Business Practice Location Address Fax Number:
503-232-5653
Provider Enumeration Date:
10/20/2009