Provider First Line Business Practice Location Address:
122 NE 47TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97365-1429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-574-0841
Provider Business Practice Location Address Fax Number:
541-574-0821
Provider Enumeration Date:
02/27/2013