Provider First Line Business Practice Location Address:
1923 NE BROADWAY ST
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:
97232-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-493-1221
Provider Business Practice Location Address Fax Number:
503-827-3917
Provider Enumeration Date:
05/24/2007