Provider First Line Business Practice Location Address:
4370 NE HALSEY ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-1543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-220-1332
Provider Business Practice Location Address Fax Number:
503-220-8531
Provider Enumeration Date:
09/21/2006