Provider First Line Business Practice Location Address:
112 SE DOUGLAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97365-4427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-265-1954
Provider Business Practice Location Address Fax Number:
541-265-6064
Provider Enumeration Date:
01/27/2007