Provider First Line Business Practice Location Address:
412 ALDER ST UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARBOR
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-9014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-813-1863
Provider Business Practice Location Address Fax Number:
541-813-1863
Provider Enumeration Date:
02/11/2026