Provider First Line Business Practice Location Address:
5139 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:
97203-4403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-238-0769
Provider Business Practice Location Address Fax Number:
503-889-2599
Provider Enumeration Date:
05/26/2006