Provider First Line Business Practice Location Address:
114 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:
503-281-4656
Provider Business Practice Location Address Fax Number:
503-288-3289
Provider Enumeration Date:
03/27/2009