Provider First Line Business Practice Location Address:
5210 SE 48TH AVE UNIT A
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:
97206-5615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-791-1968
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2026