Provider First Line Business Practice Location Address:
3100 NE 28TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LINCOLN CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97367-4524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-994-8114
Provider Business Practice Location Address Fax Number:
541-994-5679
Provider Enumeration Date:
06/04/2006