Provider First Line Business Practice Location Address:
221 NE 122ND 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:
97230-2104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-261-2559
Provider Business Practice Location Address Fax Number:
503-261-2563
Provider Enumeration Date:
11/06/2010