Provider First Line Business Practice Location Address: 
414 N 2ND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JEFFERSON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97352-9706
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-374-4343
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/10/2021