Provider First Line Business Practice Location Address:
1015 WEBBER ST STE 100
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:
97058-3527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-4804
Provider Business Practice Location Address Fax Number:
541-296-3741
Provider Enumeration Date:
11/30/2016