Provider First Line Business Practice Location Address:
407 NE 12TH AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-234-1493
Provider Business Practice Location Address Fax Number:
503-234-7220
Provider Enumeration Date:
04/02/2009