Provider First Line Business Practice Location Address: 
111 E 16TH AVE
    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: 
97401-4017
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-972-3513
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/20/2022