Provider First Line Business Practice Location Address:
2015 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-3912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-679-8292
Provider Business Practice Location Address Fax Number:
503-206-5910
Provider Enumeration Date:
04/07/2007