Provider First Line Business Practice Location Address:
965 NW 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-6915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-493-3198
Provider Business Practice Location Address Fax Number:
503-492-1384
Provider Enumeration Date:
03/18/2026