Provider First Line Business Practice Location Address:
8401 NE HALSEY ST STE 206
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:
97220-5670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-724-3725
Provider Business Practice Location Address Fax Number:
503-297-2937
Provider Enumeration Date:
11/21/2025