Provider First Line Business Practice Location Address:
228 NW B ST
Provider Second Line Business Practice Location Address:
UPPER UNIT
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97526-2032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-761-6764
Provider Business Practice Location Address Fax Number:
541-592-6479
Provider Enumeration Date:
06/01/2007