Provider First Line Business Practice Location Address:
61615 ATHLETIC CLUB DR
Provider Second Line Business Practice Location Address:
TAI CENTRAL OREGON ATHLETIC CLUB
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97702-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-382-7890
Provider Business Practice Location Address Fax Number:
541-382-7498
Provider Enumeration Date:
11/25/2005