Provider First Line Business Practice Location Address:
1942 NW KEARNEY ST STE 24
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:
97209-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-221-7074
Provider Business Practice Location Address Fax Number:
503-636-8784
Provider Enumeration Date:
02/01/2007