Provider First Line Business Practice Location Address:
5847 NE 122ND AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230-1079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-256-3401
Provider Business Practice Location Address Fax Number:
503-261-2600
Provider Enumeration Date:
05/30/2007