Provider First Line Business Practice Location Address:
1705 MAIN ST
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
BAKER CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97814-3453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-523-4385
Provider Business Practice Location Address Fax Number:
541-523-4406
Provider Enumeration Date:
04/06/2012