Provider First Line Business Practice Location Address:
618 N.W. 12TH AVE.
Provider Second Line Business Practice Location Address:
#409
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-412-5242
Provider Business Practice Location Address Fax Number:
949-266-5618
Provider Enumeration Date:
11/29/2006