Provider First Line Business Practice Location Address:
135 NW 9TH AVE APT 214
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:
97209-3467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-495-3914
Provider Business Practice Location Address Fax Number:
503-296-2331
Provider Enumeration Date:
03/02/2026