Provider First Line Business Practice Location Address:
12741 NE HALSEY 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:
97230-2343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-255-0306
Provider Business Practice Location Address Fax Number:
503-257-1452
Provider Enumeration Date:
03/17/2021