Provider First Line Business Practice Location Address:
2223 NE 47TH AVE
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:
97213-1911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-317-7814
Provider Business Practice Location Address Fax Number:
971-255-0466
Provider Enumeration Date:
10/04/2006