Provider First Line Business Practice Location Address:
203 E FIRST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLOWA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97885-9999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-886-2431
Provider Business Practice Location Address Fax Number:
541-886-2211
Provider Enumeration Date:
04/13/2007