Provider First Line Business Practice Location Address:
133 E MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-852-7147
Provider Business Practice Location Address Fax Number:
503-852-7149
Provider Enumeration Date:
07/21/2005