Provider First Line Business Practice Location Address:
721 N. MAIN ST.
Provider Second Line Business Practice Location Address:
SPACE A
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-535-3590
Provider Business Practice Location Address Fax Number:
541-535-1148
Provider Enumeration Date:
04/23/2007