Provider First Line Business Practice Location Address:
1805 E 19TH 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:
97058-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-2201
Provider Business Practice Location Address Fax Number:
541-296-1237
Provider Enumeration Date:
12/28/2006