Provider First Line Business Practice Location Address:
6850 N LOMBARD ST
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:
97203-6247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-286-0629
Provider Business Practice Location Address Fax Number:
503-240-2724
Provider Enumeration Date:
06/20/2006