Provider First Line Business Practice Location Address:
1920 NW JOHNSON ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209-1325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-719-5499
Provider Business Practice Location Address Fax Number:
503-719-5499
Provider Enumeration Date:
09/06/2006