Provider First Line Business Practice Location Address:
4509 NE SUMNER 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:
97218-1547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-463-6171
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2025