Provider First Line Business Practice Location Address:
2311 NW NORTHRUP ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-227-1636
Provider Business Practice Location Address Fax Number:
503-227-3048
Provider Enumeration Date:
07/17/2014