Provider First Line Business Practice Location Address:
2456 NW NORTHRUP ST STE 1A
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:
97210-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-229-8490
Provider Business Practice Location Address Fax Number:
503-224-0740
Provider Enumeration Date:
08/24/2011