Provider First Line Business Practice Location Address:
2719 SE 21ST AVENUE
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:
97202-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-546-2565
Provider Business Practice Location Address Fax Number:
503-546-2680
Provider Enumeration Date:
01/19/2007