Provider First Line Business Practice Location Address:
419 NW 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-3470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-224-2273
Provider Business Practice Location Address Fax Number:
503-224-1176
Provider Enumeration Date:
04/23/2007