Provider First Line Business Practice Location Address:
1944 NE 45TH AVE
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:
97213-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-319-0045
Provider Business Practice Location Address Fax Number:
503-296-5712
Provider Enumeration Date:
12/06/2006