Provider First Line Business Practice Location Address: 
5432 N MARYLAND 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: 
97217-4548
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
802-399-6426
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/12/2011