Provider First Line Business Practice Location Address:
8624 SE 13TH 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:
97202-7166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-232-0014
Provider Business Practice Location Address Fax Number:
503-232-0144
Provider Enumeration Date:
04/26/2007