Provider First Line Business Practice Location Address:
1015 NW 22ND 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:
97210-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-413-8938
Provider Business Practice Location Address Fax Number:
503-413-6380
Provider Enumeration Date:
10/03/2005