Provider First Line Business Practice Location Address:
3115 NE 47TH 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:
97213-1822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-741-4737
Provider Business Practice Location Address Fax Number:
833-645-0023
Provider Enumeration Date:
07/05/2009