Provider First Line Business Practice Location Address:
3425 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKER CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97814-1340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-516-0083
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2019