Provider First Line Business Practice Location Address:
4215 N MICHIGAN 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:
97217-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-442-4862
Provider Business Practice Location Address Fax Number:
503-926-9161
Provider Enumeration Date:
04/24/2007