Provider First Line Business Practice Location Address: 
4530 SW HALL BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BEAVERTON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97005-0504
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-709-3882
    Provider Business Practice Location Address Fax Number: 
503-389-1591
    Provider Enumeration Date: 
08/29/2012