Provider First Line Business Practice Location Address:
75167 LOWER DIAMOND LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLOWA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97885-8167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-886-3302
Provider Business Practice Location Address Fax Number:
541-886-3300
Provider Enumeration Date:
11/30/2007