Provider First Line Business Practice Location Address:
2348 NW LOVEJOY ST
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:
97210-3022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-224-7224
Provider Business Practice Location Address Fax Number:
503-224-1345
Provider Enumeration Date:
09/23/2011