Provider First Line Business Practice Location Address:
2534 NW VAUGHN ST
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:
97210-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-477-8881
Provider Business Practice Location Address Fax Number:
503-719-4695
Provider Enumeration Date:
04/29/2011