Provider First Line Business Practice Location Address:
ACTIVSPACE 1722 NW RALEIGH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-887-3608
Provider Business Practice Location Address Fax Number:
503-809-5088
Provider Enumeration Date:
12/19/2023