Provider First Line Business Practice Location Address:
840 A ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97477-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-746-8401
Provider Business Practice Location Address Fax Number:
541-746-8402
Provider Enumeration Date:
05/23/2005