Provider First Line Business Practice Location Address:
5417 NE. 25TH AVENUE
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:
97217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-402-8119
Provider Business Practice Location Address Fax Number:
503-282-6722
Provider Enumeration Date:
01/31/2007