Provider First Line Business Practice Location Address:
2001 NW 19TH 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:
97209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-723-5049
Provider Business Practice Location Address Fax Number:
503-655-9305
Provider Enumeration Date:
06/26/2008