Provider First Line Business Practice Location Address:
5023 NE 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:
97218-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-4249
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2012