Provider First Line Business Practice Location Address:
97900 SHOPPING CENTER AVE UNIT 9B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARBOR
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97415-9412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-469-3989
Provider Business Practice Location Address Fax Number:
541-469-7517
Provider Enumeration Date:
08/31/2006