Provider First Line Business Practice Location Address:
13128 SE COOPER 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:
97236-4573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-803-2177
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2026