Provider First Line Business Practice Location Address:
224 NE 28TH 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:
97232-3148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-545-9192
Provider Business Practice Location Address Fax Number:
971-200-1448
Provider Enumeration Date:
07/08/2010