Provider First Line Business Practice Location Address:
751 MYRTLE 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:
97058-4261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-386-9511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2015