Provider First Line Business Practice Location Address:
1814 NORTHEAST 41ST AVENUE
Provider Second Line Business Practice Location Address:
HOLLYWOOD MARKET SQUARE
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97212-5332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-249-7627
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006