Provider First Line Business Practice Location Address:
205 NE 50TH 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:
97213-2909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-2678
Provider Business Practice Location Address Fax Number:
503-215-2688
Provider Enumeration Date:
06/27/2008