Provider First Line Business Practice Location Address:
4924 NE MULTNOMAH 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:
97213-2828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-224-5808
Provider Business Practice Location Address Fax Number:
833-619-1215
Provider Enumeration Date:
02/28/2007