Provider First Line Business Practice Location Address:
2344 SE 47TH AVE
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:
97215-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-208-6454
Provider Business Practice Location Address Fax Number:
503-882-6609
Provider Enumeration Date:
02/24/2026