Provider First Line Business Practice Location Address:
6110 NE PRESCOTT ST APT 12
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:
97218-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-985-9220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2026