Provider First Line Business Practice Location Address:
2538 NE BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232-1872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-8600
Provider Business Practice Location Address Fax Number:
503-287-0967
Provider Enumeration Date:
09/14/2007