Provider First Line Business Practice Location Address:
115 SE 7TH 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:
97526-3051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-956-7545
Provider Business Practice Location Address Fax Number:
541-956-7548
Provider Enumeration Date:
10/22/2010