Provider First Line Business Practice Location Address:
3246 N LOMBARD ST
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:
97217-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-285-5956
Provider Business Practice Location Address Fax Number:
503-285-7859
Provider Enumeration Date:
01/29/2007