Provider First Line Business Practice Location Address:
775 S.W. 9TH STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-265-2007
Provider Business Practice Location Address Fax Number:
541-265-3533
Provider Enumeration Date:
12/29/2006