Provider First Line Business Practice Location Address:
2509 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97814-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-579-2156
Provider Business Practice Location Address Fax Number:
541-239-5506
Provider Enumeration Date:
05/10/2021