Provider First Line Business Practice Location Address:
601 WHISKEY CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLOWA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97885-7129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-886-3142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2008