Provider First Line Business Practice Location Address: 
195 N ADAIR ST.
    Provider Second Line Business Practice Location Address: 
STE E
    Provider Business Practice Location Address City Name: 
CORNELIUS
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97113
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-357-4482
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/22/2014