Provider First Line Business Practice Location Address:
3517 NE M L KING BLVD
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:
97212-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-475-8583
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2026