Provider First Line Business Practice Location Address:
5725 NE PRESCOTT 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:
97218-2275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-402-8101
Provider Business Practice Location Address Fax Number:
503-249-9510
Provider Enumeration Date:
01/27/2021