Provider First Line Business Practice Location Address:
140 SW 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-1415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-663-4104
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2025