Provider First Line Business Practice Location Address: 
860 BELTLINE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRINGFIELD
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97477-1091
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-344-4168
    Provider Business Practice Location Address Fax Number: 
458-201-8510
    Provider Enumeration Date: 
07/24/2014