Provider First Line Business Practice Location Address:
5021 SE 109TH 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:
97266-3422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-838-7621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2026