Provider First Line Business Practice Location Address:
1210 DRY HOLLOW RD STE 4
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:
97058-3167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-4804
Provider Business Practice Location Address Fax Number:
541-296-3741
Provider Enumeration Date:
12/05/2016