Provider First Line Business Practice Location Address: 
1615 E BARNETT RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MEDFORD
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97504-8284
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
458-225-9887
    Provider Business Practice Location Address Fax Number: 
866-611-1993
    Provider Enumeration Date: 
03/23/2023