Provider First Line Business Practice Location Address:
13 NW 23RD PL
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:
97210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-226-6211
Provider Business Practice Location Address Fax Number:
503-226-5390
Provider Enumeration Date:
12/18/2006