Provider First Line Business Practice Location Address:
1450 N PRESCOTT ST
Provider Second Line Business Practice Location Address:
APT 411
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97217-3202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-780-7195
Provider Business Practice Location Address Fax Number:
503-288-8972
Provider Enumeration Date:
03/07/2017