Provider First Line Business Practice Location Address:
4453 NE FAILING 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:
97213-1055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-264-9111
Provider Business Practice Location Address Fax Number:
503-281-4072
Provider Enumeration Date:
11/18/2025