Provider First Line Business Practice Location Address:
2222 E POWELL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97080-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-360-0272
Provider Business Practice Location Address Fax Number:
971-360-0273
Provider Enumeration Date:
01/16/2026