Provider First Line Business Practice Location Address:
3636 NE 9TH 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:
97212-2122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-247-8336
Provider Business Practice Location Address Fax Number:
503-247-8368
Provider Enumeration Date:
07/05/2006