Provider First Line Business Practice Location Address:
1455 18TH 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:
97477-3425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-726-9644
Provider Business Practice Location Address Fax Number:
937-398-0629
Provider Enumeration Date:
03/17/2026