Provider First Line Business Practice Location Address:
757 NE 1ST STREET
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:
97754-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-323-4272
Provider Business Practice Location Address Fax Number:
541-383-1883
Provider Enumeration Date:
01/18/2013