Provider First Line Business Practice Location Address:
7573 N EDGEWATER 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:
97203-5081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-319-0828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2026