Provider First Line Business Practice Location Address: 
9155 SW BARNES RD
    Provider Second Line Business Practice Location Address: 
GERRY FRANK CENTER FOR CHILDREN
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97225-6625
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-216-8369
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/11/2016