Provider First Line Business Practice Location Address:
2111 NE 40TH 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:
97212-5406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-2139
Provider Business Practice Location Address Fax Number:
503-287-2879
Provider Enumeration Date:
12/16/2006