Provider First Line Business Practice Location Address:
2285 NW JOHNSON 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:
97210-3236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-445-5870
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2009