Provider First Line Business Practice Location Address:
4822 SW 35TH PL
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:
97221-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-978-5866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2026