Provider First Line Business Practice Location Address:
1962 NW KEARNEY ST STE L102
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:
97209-1459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-525-1148
Provider Business Practice Location Address Fax Number:
503-295-7898
Provider Enumeration Date:
12/07/2006