Provider First Line Business Practice Location Address:
218 NORTH PINE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALFWAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-742-5023
Provider Business Practice Location Address Fax Number:
541-742-7210
Provider Enumeration Date:
09/11/2006