Provider First Line Business Practice Location Address:
16410 THIRD STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LA PINE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97739-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-536-2911
Provider Business Practice Location Address Fax Number:
541-536-2913
Provider Enumeration Date:
05/14/2009