Provider First Line Business Practice Location Address:
115 PHILLIPS ST
Provider Second Line Business Practice Location Address:
PO BX 732
Provider Business Practice Location Address City Name:
CANYONVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97417-8703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-839-4800
Provider Business Practice Location Address Fax Number:
541-839-4800
Provider Enumeration Date:
04/23/2013