Provider First Line Business Practice Location Address:
2520 SE 145TH AVE STE C
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:
97236-2671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-653-4093
Provider Business Practice Location Address Fax Number:
503-653-4891
Provider Enumeration Date:
01/17/2023