Provider First Line Business Practice Location Address:
312 W 21ST PLACE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-980-5372
Provider Business Practice Location Address Fax Number:
541-296-5662
Provider Enumeration Date:
06/01/2011