Provider First Line Business Practice Location Address:
1426 NE HIGHLAND 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:
97211-4134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-206-5894
Provider Business Practice Location Address Fax Number:
503-206-5898
Provider Enumeration Date:
08/10/2026