Provider First Line Business Practice Location Address:
1012 TREVITT 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:
97058-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-6495
Provider Business Practice Location Address Fax Number:
541-296-6497
Provider Enumeration Date:
10/18/2011