Provider First Line Business Practice Location Address:
820 NW 21ST AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209-1409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-890-1620
Provider Business Practice Location Address Fax Number:
503-233-8905
Provider Enumeration Date:
11/09/2005