Provider First Line Business Practice Location Address:
21 NE SEVENTH 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:
97232-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-231-4876
Provider Business Practice Location Address Fax Number:
503-232-0256
Provider Enumeration Date:
04/19/2006