Provider First Line Business Practice Location Address:
1525 NE WEIDLER ST
Provider Second Line Business Practice Location Address:
1944 NW KEARNEY
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232-1410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-805-1091
Provider Business Practice Location Address Fax Number:
503-246-0167
Provider Enumeration Date:
08/25/2006