Provider First Line Business Practice Location Address: 
92 NW GLENHART AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WINSTON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97496
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-492-4550
    Provider Business Practice Location Address Fax Number: 
541-492-4553
    Provider Enumeration Date: 
02/06/2008