Provider First Line Business Practice Location Address:
420 W 12TH 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:
97058-1563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-290-0449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2014