Provider First Line Business Practice Location Address:
205 SOUTH EIGHTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKESIDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-759-2408
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2010