Provider First Line Business Practice Location Address:
2991 HIGH DESERT LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UMATILLA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97882-6306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-676-9161
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2025