Provider First Line Business Practice Location Address:
2800 N. VANCOUVER AVE
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97227-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-249-8851
Provider Business Practice Location Address Fax Number:
503-282-3409
Provider Enumeration Date:
10/31/2006