Provider First Line Business Practice Location Address:
1196 S. 8TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97351-1540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-999-6686
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2016