Provider First Line Business Practice Location Address:
231 SE 12TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97214-1342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-546-9975
Provider Business Practice Location Address Fax Number:
503-546-9976
Provider Enumeration Date:
03/28/2007