Provider First Line Business Practice Location Address:
1023 W 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-298-5158
Provider Business Practice Location Address Fax Number:
541-298-3864
Provider Enumeration Date:
05/04/2006