Provider First Line Business Practice Location Address:
329 SOUTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-838-1633
Provider Business Practice Location Address Fax Number:
503-838-4640
Provider Enumeration Date:
11/14/2005