Provider First Line Business Practice Location Address:
147 S 52ND PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97478-6210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-746-1166
Provider Business Practice Location Address Fax Number:
541-746-6736
Provider Enumeration Date:
03/27/2017