Provider First Line Business Practice Location Address:
1005 NE 112TH 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:
97220-3170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-583-3545
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2011