Provider First Line Business Practice Location Address:
4037 NE 8TH AVE
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:
97212-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-998-0252
Provider Business Practice Location Address Fax Number:
503-239-4413
Provider Enumeration Date:
10/26/2007