Provider First Line Business Practice Location Address:
217 NE C ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97526-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-846-0590
Provider Business Practice Location Address Fax Number:
541-846-0590
Provider Enumeration Date:
09/03/2007