Provider First Line Business Practice Location Address:
2170 SE 96TH AVE APT F
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:
97216-2662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-810-7224
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2026