Provider First Line Business Practice Location Address:
314 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYONVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97417-0746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-839-4452
Provider Business Practice Location Address Fax Number:
541-839-4254
Provider Enumeration Date:
01/30/2007