Provider First Line Business Practice Location Address:
1420 SW BROADWAY
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:
97201-3413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-222-1955
Provider Business Practice Location Address Fax Number:
503-222-1485
Provider Enumeration Date:
12/05/2005