Provider First Line Business Practice Location Address:
330 SE BAKER ST
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-6038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-883-0333
Provider Business Practice Location Address Fax Number:
503-883-0330
Provider Enumeration Date:
01/17/2008