Provider First Line Business Practice Location Address:
2021 COURT AVE
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:
97814-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-249-9255
Provider Business Practice Location Address Fax Number:
208-639-9581
Provider Enumeration Date:
09/26/2017