Provider First Line Business Practice Location Address:
357 NE COURT 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:
97754-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-504-7535
Provider Business Practice Location Address Fax Number:
541-504-7535
Provider Enumeration Date:
07/21/2021