Provider First Line Business Practice Location Address:
2246 SE 90TH AVE
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:
97216-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-491-3964
Provider Business Practice Location Address Fax Number:
503-894-8787
Provider Enumeration Date:
09/22/2025