Provider First Line Business Practice Location Address:
1716 E 12TH ST
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:
97058-3137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-1006
Provider Business Practice Location Address Fax Number:
541-298-1613
Provider Enumeration Date:
01/17/2012