Provider First Line Business Practice Location Address: 
1318 NW 20TH AVE STE A3
    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: 
97209-1671
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-953-5012
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/27/2019