Provider First Line Business Practice Location Address:
1 12TH ST
Provider Second Line Business Practice Location Address:
SUITE #4
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97103-4146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-325-3623
Provider Business Practice Location Address Fax Number:
503-325-4986
Provider Enumeration Date:
07/18/2005