Provider First Line Business Practice Location Address:
16440 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PINE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-536-2175
Provider Business Practice Location Address Fax Number:
541-536-1206
Provider Enumeration Date:
12/11/2006