Provider First Line Business Practice Location Address:
32433 HIGHWAY 228
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HALSEY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97348-9719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-762-6149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2026