Provider First Line Business Practice Location Address:
3016 NE BROADWAY ST
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:
97232-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-287-6636
Provider Business Practice Location Address Fax Number:
503-287-4044
Provider Enumeration Date:
11/22/2005