Provider First Line Business Practice Location Address:
1427 NW 23RD AVE STE 3
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:
97210-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-221-6631
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2008