Provider First Line Business Practice Location Address:
2055 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97814-3370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-5741
Provider Business Practice Location Address Fax Number:
541-963-6332
Provider Enumeration Date:
10/24/2025