Provider First Line Business Practice Location Address:
1615 NW 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-223-8719
Provider Business Practice Location Address Fax Number:
503-223-3237
Provider Enumeration Date:
05/05/2006