Provider First Line Business Practice Location Address:
3940 SW PLUM ST
Provider Second Line Business Practice Location Address:
APT#2
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-6027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-484-6061
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2013