Provider First Line Business Practice Location Address:
2833 SE 45TH AVE UNIT B
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:
97206-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-6736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2023