Provider First Line Business Practice Location Address:
1715 E BURNSIDE 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:
97214-1531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-234-4622
Provider Business Practice Location Address Fax Number:
503-788-6399
Provider Enumeration Date:
10/27/2006