Provider First Line Business Practice Location Address:
5606 NE 23RD 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:
97211-5531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-232-2841
Provider Business Practice Location Address Fax Number:
503-296-2637
Provider Enumeration Date:
09/30/2006