Provider First Line Business Practice Location Address:
950 NE ELM
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:
97754-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-7667
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2009