Provider First Line Business Practice Location Address: 
3196 MARINE DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ASTORIA
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97103-2734
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-341-3164
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/16/2006