Provider First Line Business Practice Location Address:
5608 N HOUGHTON 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:
97203-6048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-704-1195
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2026