Provider First Line Business Practice Location Address:
12077 NW WELSH DR
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:
97229-8302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-407-8156
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2026