Provider First Line Business Practice Location Address:
530 NW 3RD ST
Provider Second Line Business Practice Location Address:
SUITE A
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:
541-265-8680
Provider Business Practice Location Address Fax Number:
541-265-9595
Provider Enumeration Date:
12/20/2009