Provider First Line Business Practice Location Address:
2721 NE 57TH AVE
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:
97213-3415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-0926
Provider Business Practice Location Address Fax Number:
503-282-0930
Provider Enumeration Date:
08/03/2005