Provider First Line Business Practice Location Address:
7617 N DECATUR ST
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:
97203-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-283-5518
Provider Business Practice Location Address Fax Number:
503-808-9120
Provider Enumeration Date:
04/04/2008