Provider First Line Business Practice Location Address:
920 NW 23RD 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:
97210-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-889-9020
Provider Business Practice Location Address Fax Number:
503-889-9015
Provider Enumeration Date:
05/17/2016