Provider First Line Business Practice Location Address:
12428 NE HALSEY ST
Provider Second Line Business Practice Location Address:
#65
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-259-8022
Provider Business Practice Location Address Fax Number:
971-484-4002
Provider Enumeration Date:
04/09/2025