Provider First Line Business Practice Location Address:
17 S 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NYSSA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97913-3815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-372-5738
Provider Business Practice Location Address Fax Number:
541-372-5732
Provider Enumeration Date:
06/26/2006