Provider First Line Business Practice Location Address: 
1060 W ELM AVE
    Provider Second Line Business Practice Location Address: 
#115
    Provider Business Practice Location Address City Name: 
HERMISTON
    Provider Business Practice Location Address State Name: 
OR
    Provider Business Practice Location Address Postal Code: 
97838-2721
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-554-2133
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/28/2011