Provider First Line Business Practice Location Address:
3840 NE COUCH 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:
97232-3426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-230-6164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2007