Provider First Line Business Practice Location Address:
1213 N AINSWORTH ST
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:
97217-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-261-6773
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2007