Provider First Line Business Practice Location Address:
1925 SE 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:
97215-3209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-218-3709
Provider Business Practice Location Address Fax Number:
503-710-9072
Provider Enumeration Date:
12/31/2006