Provider First Line Business Practice Location Address:
1201--C NE 7TH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-955-9698
Provider Business Practice Location Address Fax Number:
541-955-9698
Provider Enumeration Date:
05/02/2006