Provider First Line Business Practice Location Address:
2135 NE 55TH 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:
97213-2622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-384-8315
Provider Business Practice Location Address Fax Number:
503-328-7083
Provider Enumeration Date:
09/29/2009