Provider First Line Business Practice Location Address:
3043 NE 28TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97367-4518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-996-7160
Provider Business Practice Location Address Fax Number:
541-996-7223
Provider Enumeration Date:
11/07/2006