Provider First Line Business Practice Location Address:
1128 SE 141ST 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:
97233-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-206-5980
Provider Business Practice Location Address Fax Number:
503-447-4702
Provider Enumeration Date:
01/15/2026