Provider First Line Business Practice Location Address: 
9450 SW BARNES RD
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97225-6619
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-292-9560
    Provider Business Practice Location Address Fax Number: 
503-292-9510
    Provider Enumeration Date: 
02/08/2006