Provider First Line Business Practice Location Address:
2520 NW UPSHUR ST
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:
97210-2550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-358-0923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006