Provider First Line Business Practice Location Address:
3002 NE AINSWORTH 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:
97211-6752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-229-6060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2026