Provider First Line Business Practice Location Address:
129 NE 102ND AVE STE A
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:
97220-4102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-837-6655
Provider Business Practice Location Address Fax Number:
866-539-5513
Provider Enumeration Date:
07/28/2025