Provider First Line Business Practice Location Address:
12003 NE AINSWORTH CIR STE 103
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:
97220-9034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-477-7748
Provider Business Practice Location Address Fax Number:
503-477-9746
Provider Enumeration Date:
11/10/2025