Provider First Line Business Practice Location Address:
3930 S KELLY 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:
97239-4315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-274-9482
Provider Business Practice Location Address Fax Number:
503-222-3539
Provider Enumeration Date:
09/16/2026