Provider First Line Business Practice Location Address:
101 SW KINKADE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97818-9001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-481-2533
Provider Business Practice Location Address Fax Number:
541-314-4448
Provider Enumeration Date:
01/22/2018