Provider First Line Business Practice Location Address: 
1655 NE 18TH ST
    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: 
97030-4113
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-665-1994
    Provider Business Practice Location Address Fax Number: 
503-489-0283
    Provider Enumeration Date: 
06/17/2020