Provider First Line Business Practice Location Address:
97900 SHOPPING CENTER AVE
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:
541-412-0250
Provider Business Practice Location Address Fax Number:
541-412-0345
Provider Enumeration Date:
04/25/2011