Provider First Line Business Practice Location Address:
2064 N KILLINGSWORTH 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:
97217-4439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-719-7742
Provider Business Practice Location Address Fax Number:
503-719-7571
Provider Enumeration Date:
06/04/2007