Provider First Line Business Practice Location Address: 
5050 NE HOYT
    Provider Second Line Business Practice Location Address: 
STE 660
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97213-2990
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-239-8430
    Provider Business Practice Location Address Fax Number: 
503-235-9342
    Provider Enumeration Date: 
07/24/2006