Provider First Line Business Practice Location Address:
3279 SE HAWTHORNE BLVD BSMT
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:
97214-5044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-358-8717
Provider Business Practice Location Address Fax Number:
503-358-8717
Provider Enumeration Date:
10/17/2007