Provider First Line Business Practice Location Address:
1309 NW 23RD 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:
97210-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-295-7941
Provider Business Practice Location Address Fax Number:
503-295-7707
Provider Enumeration Date:
02/21/2012