Provider First Line Business Practice Location Address: 
17376 NE COUCH ST APT D114
    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: 
97230-6456
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
971-563-4823
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/26/2022