Provider First Line Business Practice Location Address:
1942 NW KEARNEY ST STE 11
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:
97209-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-224-9242
Provider Business Practice Location Address Fax Number:
503-296-9395
Provider Enumeration Date:
04/17/2007