Provider First Line Business Practice Location Address:
3735 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:
97214-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-662-2023
Provider Business Practice Location Address Fax Number:
503-713-5486
Provider Enumeration Date:
02/11/2022