Provider First Line Business Practice Location Address: 
334 NE IRVING AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BEND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97701-4710
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-385-0775
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/06/2006