Provider First Line Business Practice Location Address:
12400 SE KNAPP 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:
97236-5019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-619-4737
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2024