Provider First Line Business Practice Location Address: 
902 E JACKSON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MEDFORD
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97504-7025
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-779-4893
    Provider Business Practice Location Address Fax Number: 
541-773-7714
    Provider Enumeration Date: 
08/01/2012