Provider First Line Business Practice Location Address:
5010 SE 41ST AVE APT 106
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:
97202-4278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-842-6195
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2025