Provider First Line Business Practice Location Address:
213 NE 132ND CT
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:
97230-2599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-848-9487
Provider Business Practice Location Address Fax Number:
503-946-8553
Provider Enumeration Date:
10/30/2025