Provider First Line Business Practice Location Address:
528 SE 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-420-9162
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2007