Provider First Line Business Practice Location Address:
1536 NW 23RD AVE
Provider Second Line Business Practice Location Address:
SECOND FLOOR
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-221-2155
Provider Business Practice Location Address Fax Number:
503-274-4159
Provider Enumeration Date:
05/21/2008