Provider First Line Business Practice Location Address:
8611 SW 19TH 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:
97219-4117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-936-0788
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2026