Provider First Line Business Practice Location Address:
130 NW 19TH ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97365-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-265-8455
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2009