Provider First Line Business Practice Location Address:
142 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDDLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-874-2406
Provider Business Practice Location Address Fax Number:
541-874-3256
Provider Enumeration Date:
05/27/2005