Provider First Line Business Practice Location Address:
9810 SW 34TH PL APT 6
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:
97219-6260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-705-0736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2026