Provider First Line Business Practice Location Address: 
111 N 20TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PHILOMATH
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97370-9535
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-368-4313
    Provider Business Practice Location Address Fax Number: 
541-929-4967
    Provider Enumeration Date: 
08/19/2011