Provider First Line Business Practice Location Address:
1251 NE ELM STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-1680
Provider Business Practice Location Address Fax Number:
541-447-4670
Provider Enumeration Date:
08/09/2005