Provider First Line Business Practice Location Address:
2408 SW HALSEY ST BLDG J
Provider Second Line Business Practice Location Address:
ROOM 5
Provider Business Practice Location Address City Name:
TROUTDALE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97060-1020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-661-7200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2026