Provider First Line Business Practice Location Address:
1316 SW 13TH AVENUE
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:
97201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-235-0555
Provider Business Practice Location Address Fax Number:
503-224-5726
Provider Enumeration Date:
07/26/2005