Provider First Line Business Practice Location Address:
3332 N LOMBARD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-289-1992
Provider Business Practice Location Address Fax Number:
503-289-3097
Provider Enumeration Date:
11/17/2006