Provider First Line Business Practice Location Address: 
400 INTERNATIONAL WAY STE 200
    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: 
97477-7004
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-844-0151
    Provider Business Practice Location Address Fax Number: 
541-636-2722
    Provider Enumeration Date: 
02/20/2018