Provider First Line Business Practice Location Address: 
2700 SE 26TH AVE
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97202-1288
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
971-409-0908
    Provider Business Practice Location Address Fax Number: 
503-234-6556
    Provider Enumeration Date: 
12/06/2007