Provider First Line Business Practice Location Address:
16410 3RD ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LA PINE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-536-3693
Provider Business Practice Location Address Fax Number:
541-636-9448
Provider Enumeration Date:
01/23/2007