Provider First Line Business Practice Location Address:
2805 10TH ST
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:
97814-1403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-523-2495
Provider Business Practice Location Address Fax Number:
541-523-2495
Provider Enumeration Date:
11/09/2005