Provider First Line Business Practice Location Address:
1305 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:
97212-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-866-0544
Provider Business Practice Location Address Fax Number:
503-221-8764
Provider Enumeration Date:
12/28/2006