Provider First Line Business Practice Location Address:
1700 E 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-7526
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2014