Provider First Line Business Practice Location Address:
3531 NE 15TH AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-6996
Provider Business Practice Location Address Fax Number:
503-459-4253
Provider Enumeration Date:
06/08/2006