Provider First Line Business Practice Location Address:
4310 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:
97218-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-535-1143
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2011