Provider First Line Business Practice Location Address:
217 NE 146TH AVE
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-309-8724
Provider Business Practice Location Address Fax Number:
502-206-5512
Provider Enumeration Date:
07/02/2010