Provider First Line Business Practice Location Address: 
7110 SW 140TH PL
    Provider Second Line Business Practice Location Address: 
N/A
    Provider Business Practice Location Address City Name: 
BEAVERTON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97008-5556
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-928-9688
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/13/2013