Provider First Line Business Practice Location Address:
3506 N LOMBARD 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:
97217-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-289-0230
Provider Business Practice Location Address Fax Number:
503-286-5055
Provider Enumeration Date:
10/27/2005