Provider First Line Business Practice Location Address:
1060 W ELM AVE
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-2721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-567-6623
Provider Business Practice Location Address Fax Number:
541-564-0277
Provider Enumeration Date:
08/16/2005