Provider First Line Business Practice Location Address:
1004 MONMOUTH 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:
97351-1323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-838-0434
Provider Business Practice Location Address Fax Number:
503-838-4751
Provider Enumeration Date:
03/23/2007