Provider First Line Business Practice Location Address:
1270 KOT-NUM RD BOX C
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:
815-353-5943
Provider Business Practice Location Address Fax Number:
541-553-2457
Provider Enumeration Date:
08/17/2006