Provider First Line Business Practice Location Address:
12243 NE BRAZEE 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:
97230-1838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-477-8648
Provider Business Practice Location Address Fax Number:
503-477-8648
Provider Enumeration Date:
02/20/2024