Provider First Line Business Practice Location Address: 
4585 SW185TH AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BEAVERTON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97007
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-758-9863
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/24/2015