Provider First Line Business Practice Location Address:
135 NW 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97365-3640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-265-2818
Provider Business Practice Location Address Fax Number:
541-265-3274
Provider Enumeration Date:
08/12/2006