Provider First Line Business Practice Location Address: 
610 SW ALDER
    Provider Second Line Business Practice Location Address: 
STE 1105
    Provider Business Practice Location Address City Name: 
PORTLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97205-3612
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-228-1506
    Provider Business Practice Location Address Fax Number: 
503-228-1499
    Provider Enumeration Date: 
04/05/2006