Provider First Line Business Practice Location Address:
130 NW 19TH ST.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-264-8332
Provider Business Practice Location Address Fax Number:
541-264-8376
Provider Enumeration Date:
06/12/2006