Provider First Line Business Practice Location Address:
7452 SW 52ND AVE
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:
97219-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-916-6308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2026