Provider First Line Business Practice Location Address:
1419 NE 69TH 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:
97213-5301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-254-1545
Provider Business Practice Location Address Fax Number:
503-525-2846
Provider Enumeration Date:
10/06/2011