Provider First Line Business Practice Location Address:
1924 NE COUCH 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:
97232-3023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-788-7726
Provider Business Practice Location Address Fax Number:
503-788-7729
Provider Enumeration Date:
10/11/2006