Provider First Line Business Practice Location Address:
25198 HWY 395 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97820-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-575-0962
Provider Business Practice Location Address Fax Number:
541-575-0962
Provider Enumeration Date:
08/23/2006