Provider First Line Business Practice Location Address:
161 NE 82ND AVE APT 146
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:
97220-6004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-703-3010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2026