Provider First Line Business Practice Location Address:
4713 N LAGOON 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:
97217-7644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-283-1433
Provider Business Practice Location Address Fax Number:
503-247-3250
Provider Enumeration Date:
12/01/2006