Provider First Line Business Practice Location Address:
1016 SE 12TH 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:
97214-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-283-0380
Provider Business Practice Location Address Fax Number:
503-281-0245
Provider Enumeration Date:
03/01/2007