Provider First Line Business Practice Location Address:
7915 SE ALDER 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:
97215-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-504-7149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2026