Provider First Line Business Practice Location Address: 
1002 N BOONES FERRY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WOODBURN
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97071-9602
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-981-9526
    Provider Business Practice Location Address Fax Number: 
503-414-8535
    Provider Enumeration Date: 
06/16/2011