Provider First Line Business Practice Location Address:
1715 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-3136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-8406
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2014