Provider First Line Business Practice Location Address:
1815 E 15TH ST STE B
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:
97058-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-316-6575
Provider Business Practice Location Address Fax Number:
541-210-8913
Provider Enumeration Date:
02/05/2020