Provider First Line Business Practice Location Address: 
320 CENTRAL AVE STE 304
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COOS BAY
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97420-2241
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-269-0800
    Provider Business Practice Location Address Fax Number: 
541-269-0444
    Provider Enumeration Date: 
11/28/2014