Provider First Line Business Practice Location Address:
26B NE 76TH AVE UNIT B
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:
97213-6323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-333-0923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2026