Provider First Line Business Practice Location Address:
205 NE 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-1925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-416-1095
Provider Business Practice Location Address Fax Number:
541-416-0991
Provider Enumeration Date:
08/07/2007