Provider First Line Business Practice Location Address:
929 NE 181ST AVE.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-666-9895
Provider Business Practice Location Address Fax Number:
503-666-8165
Provider Enumeration Date:
10/02/2009