Provider First Line Business Practice Location Address:
2115 NE 42ND 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:
97213-1321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-954-1372
Provider Business Practice Location Address Fax Number:
503-954-1392
Provider Enumeration Date:
10/06/2006