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
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:
02/07/2012