Provider First Line Business Practice Location Address:
2422 NE FREMONT 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:
97212-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-287-1554
Provider Business Practice Location Address Fax Number:
503-280-8773
Provider Enumeration Date:
07/05/2005