Provider First Line Business Practice Location Address:
2929 SW MULTNOMAH BLVD
Provider Second Line Business Practice Location Address:
SUITE 203A
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-4025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-449-0244
Provider Business Practice Location Address Fax Number:
503-244-7567
Provider Enumeration Date:
10/31/2005