Provider First Line Business Practice Location Address:
2104 NW EVERETT 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:
97210-3526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-222-1432
Provider Business Practice Location Address Fax Number:
503-222-1426
Provider Enumeration Date:
12/27/2006