Provider First Line Business Practice Location Address:
1425 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:
97217-4541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-575-9402
Provider Business Practice Location Address Fax Number:
844-234-8735
Provider Enumeration Date:
10/02/2012