Provider First Line Business Practice Location Address: 
1100 7TH AVE SW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALBANY
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97321-1925
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-812-4970
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/21/2011