Provider First Line Business Practice Location Address:
1130 NW 22ND AVE SUITE 105
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:
97210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-413-8122
Provider Business Practice Location Address Fax Number:
503-413-8453
Provider Enumeration Date:
10/03/2011