Provider First Line Business Practice Location Address:
1340 SW BERTHA BLVD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-2097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-880-9204
Provider Business Practice Location Address Fax Number:
360-574-5991
Provider Enumeration Date:
09/10/2007