Provider First Line Business Practice Location Address:
5318 NE IRVING ST
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:
97213-3158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-1939
Provider Business Practice Location Address Fax Number:
503-284-3991
Provider Enumeration Date:
07/01/2006