Provider First Line Business Practice Location Address: 
1705 WAVERLY DR SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALBANY
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97322-6952
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-967-8221
    Provider Business Practice Location Address Fax Number: 
541-967-0054
    Provider Enumeration Date: 
04/11/2006