Provider First Line Business Practice Location Address:
6635 N BALTIMORE AVE
Provider Second Line Business Practice Location Address:
SUITE 228
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97203-5454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-477-9527
Provider Business Practice Location Address Fax Number:
503-477-9529
Provider Enumeration Date:
09/03/2009