Provider First Line Business Practice Location Address: 
4300 NE FREMONT ST.
    Provider Second Line Business Practice Location Address: 
STE.230
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97213
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-477-7907
    Provider Business Practice Location Address Fax Number: 
503-477-7913
    Provider Enumeration Date: 
10/22/2014