Provider First Line Business Practice Location Address:
911 NW 18TH AVE
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:
97209-2324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-227-3666
Provider Business Practice Location Address Fax Number:
503-227-2234
Provider Enumeration Date:
07/26/2007