Provider First Line Business Practice Location Address:
6505 SE CLATSOP ST 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:
97206-8826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-810-5242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2025