Provider First Line Business Practice Location Address:
2476 NW NORTHRUP ST
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-3133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-704-0579
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2016