Provider First Line Business Practice Location Address:
1318 NW 20TH AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-227-8882
Provider Business Practice Location Address Fax Number:
503-227-8058
Provider Enumeration Date:
05/05/2007