Provider First Line Business Practice Location Address: 
12220 SW 1ST ST
    Provider Second Line Business Practice Location Address: 
SUITE 200
    Provider Business Practice Location Address City Name: 
BEAVERTON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97005-2889
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-775-4931
    Provider Business Practice Location Address Fax Number: 
503-788-7285
    Provider Enumeration Date: 
11/20/2013