Provider First Line Business Practice Location Address:
545 NE 47TH AVE STE 212
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:
97213-2237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-233-5925
Provider Business Practice Location Address Fax Number:
503-233-6140
Provider Enumeration Date:
10/30/2007