Provider First Line Business Practice Location Address:
8917 NE COUCH ST
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:
97220-5946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-975-7451
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2026