Provider First Line Business Practice Location Address: 
16560 S.E. 80TH AVE, PORTLAND OR 97267
    Provider Second Line Business Practice Location Address: 
19650 SE 80TH AVE
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97267
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-799-0350
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/17/2020