Provider First Line Business Practice Location Address:
2105 NE. 42ND 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:
97213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-282-0981
Provider Business Practice Location Address Fax Number:
503-282-0982
Provider Enumeration Date:
11/22/2013