Provider First Line Business Practice Location Address:
401 E 3RD ST
Provider Second Line Business Practice Location Address:
SUIT 101
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-2562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-369-4049
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2016