Provider First Line Business Practice Location Address: 
12020 NE THOMPSON ST
    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: 
97220-1875
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
971-207-0113
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/29/2009