Provider First Line Business Practice Location Address:
149 NE 102ND 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:
97220-4168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-254-7383
Provider Business Practice Location Address Fax Number:
503-254-4568
Provider Enumeration Date:
10/11/2005