Provider First Line Business Practice Location Address:
1050 SOUTHGATE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97801-3953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-276-4752
Provider Business Practice Location Address Fax Number:
541-278-2918
Provider Enumeration Date:
05/19/2006