Provider First Line Business Practice Location Address:
540 SW 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-2108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-567-4143
Provider Business Practice Location Address Fax Number:
541-567-0264
Provider Enumeration Date:
09/20/2006