Provider First Line Business Practice Location Address: 
711 MEDFORD CTR
    Provider Second Line Business Practice Location Address: 
#318
    Provider Business Practice Location Address City Name: 
MEDFORD
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97504-6772
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-840-4426
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/12/2014