Provider First Line Business Practice Location Address:
4521 SE CLAY ST
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:
97215-3152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-990-8545
Provider Business Practice Location Address Fax Number:
971-399-8545
Provider Enumeration Date:
07/03/2026