Provider First Line Business Practice Location Address: 
2135 NE 55TH 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: 
97213-2622
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-384-8315
    Provider Business Practice Location Address Fax Number: 
503-328-7083
    Provider Enumeration Date: 
09/29/2009