Provider First Line Business Practice Location Address:
5746 SE 82ND AVE
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:
97266-4816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-365-4565
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2026