Provider First Line Business Practice Location Address:
2456 NW NORTHRUP ST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-241-5117
Provider Business Practice Location Address Fax Number:
503-243-6632
Provider Enumeration Date:
11/03/2009