Provider First Line Business Practice Location Address:
112 E 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRAIRIE CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-820-3341
Provider Business Practice Location Address Fax Number:
541-820-3628
Provider Enumeration Date:
03/02/2007