Provider First Line Business Practice Location Address: 
1755 COBURG RD UNIT 401
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EUGENE
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97401-4984
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-255-3905
    Provider Business Practice Location Address Fax Number: 
541-255-3959
    Provider Enumeration Date: 
11/20/2006