Provider First Line Business Practice Location Address:
1495 NE 3RD ST
Provider Second Line Business Practice Location Address:
STE. C
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-4511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2006