Provider First Line Business Practice Location Address:
1427 NW 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-221-6631
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2007