Provider First Line Business Practice Location Address:
6324 SE 21ST 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:
97202-5442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-347-4954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2026