Provider First Line Business Practice Location Address:
855 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEELER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97147-9999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
150-336-8686
Provider Business Practice Location Address Fax Number:
150-336-8497
Provider Enumeration Date:
01/08/2007