Provider First Line Business Practice Location Address:
0224 SW HAMILTON ST
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-6418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-228-4142
Provider Business Practice Location Address Fax Number:
503-224-9283
Provider Enumeration Date:
08/25/2005