Provider First Line Business Practice Location Address:
28 NE 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADRAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-475-6171
Provider Business Practice Location Address Fax Number:
541-475-6172
Provider Enumeration Date:
06/30/2006