Provider First Line Business Practice Location Address:
707 NE KNOTT ST
Provider Second Line Business Practice Location Address:
STE 101
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:
503-287-6199
Provider Business Practice Location Address Fax Number:
503-287-0210
Provider Enumeration Date:
07/21/2006