Provider First Line Business Practice Location Address: 
55 S 5TH ST STE P
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CENTRAL POINT
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97502-2474
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-890-9714
    Provider Business Practice Location Address Fax Number: 
541-500-0910
    Provider Enumeration Date: 
10/10/2014