Provider First Line Business Practice Location Address:
2311 NW NORTHRUP
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-294-1522
Provider Business Practice Location Address Fax Number:
503-228-0312
Provider Enumeration Date:
01/24/2006