Provider First Line Business Practice Location Address:
950 NE ELM 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:
97754-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-728-7515
Provider Business Practice Location Address Fax Number:
541-416-2492
Provider Enumeration Date:
04/08/2015