Provider First Line Business Practice Location Address:
3583 NE BROADWAY 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:
97232-1820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-432-8470
Provider Business Practice Location Address Fax Number:
503-912-7018
Provider Enumeration Date:
06/08/2006