Provider First Line Business Practice Location Address:
2311 E. BURNSIDE ST.
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-388-8898
Provider Business Practice Location Address Fax Number:
209-956-4245
Provider Enumeration Date:
04/10/2007