Provider First Line Business Practice Location Address:
1413 E ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-452-0493
Provider Business Practice Location Address Fax Number:
503-452-0360
Provider Enumeration Date:
03/13/2013