Provider First Line Business Practice Location Address: 
8800 SE 80TH 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: 
97206-9270
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-771-7914
    Provider Business Practice Location Address Fax Number: 
503-771-8606
    Provider Enumeration Date: 
05/01/2012