Provider First Line Business Practice Location Address:
1423 SE 23RD 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:
97214-3908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-236-3108
Provider Business Practice Location Address Fax Number:
503-236-3239
Provider Enumeration Date:
01/08/2007