Provider First Line Business Practice Location Address:
1634 SE SALMON 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:
97214-3739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-231-6547
Provider Business Practice Location Address Fax Number:
503-231-6594
Provider Enumeration Date:
11/26/2008