Provider First Line Business Practice Location Address:
1012 SW KING 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:
97205-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-673-6246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2007