Provider First Line Business Practice Location Address:
2000 N 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97477-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-746-5437
Provider Business Practice Location Address Fax Number:
541-746-3753
Provider Enumeration Date:
12/22/2006