Provider First Line Business Practice Location Address:
628 N 1ST ST
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
LAKEVIEW
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97630-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-947-3357
Provider Business Practice Location Address Fax Number:
541-947-3368
Provider Enumeration Date:
06/10/2005