Provider First Line Business Practice Location Address:
2112 WASCO ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARM SPRINGS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97761-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-553-1634
Provider Business Practice Location Address Fax Number:
541-553-3531
Provider Enumeration Date:
02/21/2007