Provider First Line Business Practice Location Address:
5833 N LOMBARD 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:
97203-4115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-283-2852
Provider Business Practice Location Address Fax Number:
503-283-4868
Provider Enumeration Date:
06/24/2020