Provider First Line Business Practice Location Address:
1316 NW 23RD AVE
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:
97210-2602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-292-3220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2007