Provider First Line Business Practice Location Address:
5800 SE ASH 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:
97215-1293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-916-5646
Provider Business Practice Location Address Fax Number:
503-916-2659
Provider Enumeration Date:
10/30/2025