Provider First Line Business Practice Location Address:
103 N MAIN ST UNIT 3
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:
97846-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-263-5577
Provider Business Practice Location Address Fax Number:
541-263-5578
Provider Enumeration Date:
07/30/2013