Provider First Line Business Practice Location Address:
124 NW 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-948-9988
Provider Business Practice Location Address Fax Number:
866-411-9336
Provider Enumeration Date:
07/16/2008