Provider First Line Business Practice Location Address:
515 MT HOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-3190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2016