Provider First Line Business Practice Location Address: 
28467 SE K W ANDERSON RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GRESHAM
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97080-0016
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-669-1095
    Provider Business Practice Location Address Fax Number: 
503-665-3299
    Provider Enumeration Date: 
10/18/2012