Provider First Line Business Practice Location Address:
3034 NE MLK JR BLVD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-238-0769
Provider Business Practice Location Address Fax Number:
503-552-6208
Provider Enumeration Date:
04/07/2011