Provider First Line Business Practice Location Address:
2101 MAIN ST STE 206
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:
97814-2677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-519-8610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2014