Provider First Line Business Practice Location Address:
1920 NW JOHNSON
Provider Second Line Business Practice Location Address:
SUITE #111
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-335-8038
Provider Business Practice Location Address Fax Number:
503-274-0843
Provider Enumeration Date:
10/02/2006