Provider First Line Business Practice Location Address: 
15630 SE 90TH AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLACKAMAS
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97015-9729
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-657-9287
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/24/2011