Provider First Line Business Practice Location Address:
257 NE 2ND 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:
97754-1910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-5838
Provider Business Practice Location Address Fax Number:
541-447-5883
Provider Enumeration Date:
12/15/2010