Provider First Line Business Practice Location Address: 
5441 SW MACADAM AVE
    Provider Second Line Business Practice Location Address: 
SUITE 200
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97239-6106
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-841-6222
    Provider Business Practice Location Address Fax Number: 
503-841-6199
    Provider Enumeration Date: 
03/19/2012