Provider First Line Business Practice Location Address:
1317 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97477-3424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-726-7151
Provider Business Practice Location Address Fax Number:
541-746-2225
Provider Enumeration Date:
12/27/2007