Provider First Line Business Practice Location Address:
4331 NE FREMONT STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-331-3937
Provider Business Practice Location Address Fax Number:
503-528-1234
Provider Enumeration Date:
06/28/2007