Provider First Line Business Practice Location Address:
1942 NW KEARNEY ST STE 12
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:
97209-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-222-1807
Provider Business Practice Location Address Fax Number:
503-297-0885
Provider Enumeration Date:
12/26/2006