Provider First Line Business Practice Location Address:
4839 NE 42ND 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:
97218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-6469
Provider Business Practice Location Address Fax Number:
503-288-0490
Provider Enumeration Date:
09/23/2009