Provider First Line Business Practice Location Address:
14302 NE FAILING 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:
97230-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-875-5190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2025