Provider First Line Business Practice Location Address:
2805 NE MLK
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:
97212-3039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-887-4425
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2011