Provider First Line Business Practice Location Address: 
1102 NW 10TH AVE
    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: 
97209-3472
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-227-2279
    Provider Business Practice Location Address Fax Number: 
888-767-4379
    Provider Enumeration Date: 
02/21/2008