Provider First Line Business Practice Location Address:
1229 MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
PHILOMATH
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97370-9304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-602-4112
Provider Business Practice Location Address Fax Number:
541-714-3770
Provider Enumeration Date:
01/02/2007