Provider First Line Business Practice Location Address:
1620 E 12TH 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-9151
Provider Business Practice Location Address Fax Number:
541-296-9156
Provider Enumeration Date:
07/04/2006