Provider First Line Business Practice Location Address:
1103 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:
97754-1664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-306-4566
Provider Business Practice Location Address Fax Number:
541-512-7090
Provider Enumeration Date:
01/19/2022