Provider First Line Business Practice Location Address:
1324 SE SPOKANE 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:
97202-6634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-690-0306
Provider Business Practice Location Address Fax Number:
503-967-7066
Provider Enumeration Date:
07/21/2006