Provider First Line Business Practice Location Address: 
4104 SE 82ND AVENUE
    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: 
97266
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-771-4324
    Provider Business Practice Location Address Fax Number: 
503-771-4458
    Provider Enumeration Date: 
12/12/2006