Provider First Line Business Practice Location Address:
13433 SE SOUTHWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-350-0117
Provider Business Practice Location Address Fax Number:
866-740-0637
Provider Enumeration Date:
08/31/2005