Provider First Line Business Practice Location Address:
1913 NE 88TH 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:
97220-5513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-860-8913
Provider Business Practice Location Address Fax Number:
503-296-5494
Provider Enumeration Date:
05/01/2007