Provider First Line Business Practice Location Address:
2328 NE FREMONT 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:
97212-2453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-936-1731
Provider Business Practice Location Address Fax Number:
503-972-1869
Provider Enumeration Date:
08/21/2012