Provider First Line Business Practice Location Address: 
540 CATALINA DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ASHLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97520-1605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-482-3327
    Provider Business Practice Location Address Fax Number: 
541-482-7376
    Provider Enumeration Date: 
12/07/2012