Provider First Line Business Practice Location Address:
1117 SE 135TH 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:
97233-1905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-719-1172
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2026