Provider First Line Business Practice Location Address: 
6449 SE 128TH 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: 
97236-4652
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-726-3796
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/07/2011