Provider First Line Business Practice Location Address:
6434 N KERBY 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:
97217-2043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-703-5019
Provider Business Practice Location Address Fax Number:
503-235-5105
Provider Enumeration Date:
03/19/2007