Provider First Line Business Practice Location Address:
5845 NE PRESCOTT ST
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:
97218-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-810-0064
Provider Business Practice Location Address Fax Number:
503-287-3482
Provider Enumeration Date:
03/30/2007