Provider First Line Business Practice Location Address:
5520 SW MACADAM AVE
Provider Second Line Business Practice Location Address:
HARBOR SQUARE SW, SUITE 260
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-3741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-799-9519
Provider Business Practice Location Address Fax Number:
503-245-0518
Provider Enumeration Date:
11/30/2005