Provider First Line Business Practice Location Address:
124 FRONT STR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRAIRIE CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97869-0217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-820-3739
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2007