Provider First Line Business Practice Location Address:
1615 E 12TH ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-8004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-1919
Provider Business Practice Location Address Fax Number:
541-296-2253
Provider Enumeration Date:
03/09/2007