Provider First Line Business Practice Location Address:
1400 SE 19TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-994-8028
Provider Business Practice Location Address Fax Number:
541-994-8331
Provider Enumeration Date:
10/01/2007