Provider First Line Business Practice Location Address:
1815 E. 19TH
Provider Second Line Business Practice Location Address:
SUITE 1
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:
541-298-8676
Provider Business Practice Location Address Fax Number:
541-298-7746
Provider Enumeration Date:
03/20/2012