Provider First Line Business Practice Location Address:
1939 E BURNSIDE 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:
97214-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-233-6141
Provider Business Practice Location Address Fax Number:
503-233-2889
Provider Enumeration Date:
03/07/2007