Provider First Line Business Practice Location Address:
1050 W ELM AVE
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-667-4104
Provider Business Practice Location Address Fax Number:
541-667-4175
Provider Enumeration Date:
06/22/2009