Provider First Line Business Practice Location Address:
202 NW 20TH 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:
97209-1907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-274-7128
Provider Business Practice Location Address Fax Number:
503-241-5037
Provider Enumeration Date:
05/09/2006