Provider First Line Business Practice Location Address:
430 NW 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:
97754-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-416-2067
Provider Business Practice Location Address Fax Number:
541-416-2066
Provider Enumeration Date:
02/21/2008