Provider First Line Business Practice Location Address:
1470 NE 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-6846
Provider Business Practice Location Address Fax Number:
541-447-1243
Provider Enumeration Date:
05/20/2019