Provider First Line Business Practice Location Address:
140 NW 14TH 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:
97209-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-253-6613
Provider Business Practice Location Address Fax Number:
971-253-6614
Provider Enumeration Date:
03/03/2026