Provider First Line Business Practice Location Address:
1744 NE 42ND 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:
97213-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-287-0072
Provider Business Practice Location Address Fax Number:
503-517-0113
Provider Enumeration Date:
06/30/2005