Provider First Line Business Practice Location Address:
102 E WALLOWA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOSEPH
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97846-8495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-203-3634
Provider Business Practice Location Address Fax Number:
503-853-7984
Provider Enumeration Date:
11/18/2010