Provider First Line Business Practice Location Address:
1101 W 6TH ST
Provider Second Line Business Practice Location Address:
STE 100
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:
541-296-3204
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2006