Provider First Line Business Practice Location Address:
412 SW 12TH AVENUE
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:
97205-2329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-228-7134
Provider Business Practice Location Address Fax Number:
503-445-0749
Provider Enumeration Date:
09/29/2008