Provider First Line Business Practice Location Address:
118 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:
97217-2435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-288-4454
Provider Business Practice Location Address Fax Number:
503-288-1783
Provider Enumeration Date:
01/13/2012