Provider First Line Business Practice Location Address:
12808 NE CLACKAMAS 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:
97230-2313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-254-3607
Provider Business Practice Location Address Fax Number:
503-345-6632
Provider Enumeration Date:
06/15/2023