Provider First Line Business Practice Location Address:
426 NE 160TH AVE APT 20
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:
97230-5495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-660-5280
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2025