Provider First Line Business Practice Location Address:
1539 W HARVARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-673-5150
Provider Business Practice Location Address Fax Number:
541-673-7044
Provider Enumeration Date:
02/06/2008