Provider First Line Business Practice Location Address:
203 NE COURT ST
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:
97754-1935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-749-0992
Provider Business Practice Location Address Fax Number:
541-330-4613
Provider Enumeration Date:
02/09/2007