Provider First Line Business Practice Location Address: 
4560 SE INTERNATIONAL WAY
    Provider Second Line Business Practice Location Address: 
SUITE 100 CONSONUS HEALTHCARE SERVICES
    Provider Business Practice Location Address City Name: 
MILWAUKIE
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97222
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
971-206-5149
    Provider Business Practice Location Address Fax Number: 
971-206-5209
    Provider Enumeration Date: 
08/10/2007