Provider First Line Business Practice Location Address: 
4566 GOODRICH HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OAKLAND
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97462-9636
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-255-6569
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/26/2014