Provider First Line Business Practice Location Address:
10814 NE HALSEY ST
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:
97220-3047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-688-2784
Provider Business Practice Location Address Fax Number:
971-302-6649
Provider Enumeration Date:
07/02/2024