Provider First Line Business Practice Location Address:
83211 JOSEPH HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOSEPH
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97846-8151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-398-1149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2009