Provider First Line Business Practice Location Address:
1525 N HUMBOLDT ST UNIT 101
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:
97217-3673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-936-7857
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2025