Provider First Line Business Practice Location Address:
4307 NE 130TH PL
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:
97230-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-242-8777
Provider Business Practice Location Address Fax Number:
971-209-7172
Provider Enumeration Date:
10/01/2025