Provider First Line Business Practice Location Address:
134 SE 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYONVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-839-4421
Provider Business Practice Location Address Fax Number:
541-839-6080
Provider Enumeration Date:
02/15/2007