Provider First Line Business Practice Location Address:
530 NW 3RD ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97365-3646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-819-9789
Provider Business Practice Location Address Fax Number:
541-272-5288
Provider Enumeration Date:
01/31/2017