Provider First Line Business Practice Location Address:
1020 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON FREEWATER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97862-1534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-588-2924
Provider Business Practice Location Address Fax Number:
509-588-4564
Provider Enumeration Date:
12/22/2006