Provider First Line Business Practice Location Address:
821 NE HIGHWAY 99W STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-2733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-472-4649
Provider Business Practice Location Address Fax Number:
503-434-1679
Provider Enumeration Date:
08/24/2005