Provider First Line Business Practice Location Address:
1928 COURT AVE
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:
97814-3445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-523-9664
Provider Business Practice Location Address Fax Number:
541-523-9665
Provider Enumeration Date:
06/16/2016