Provider First Line Business Practice Location Address:
1251 NE ELM 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:
97754-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-323-5330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2012