Provider First Line Business Practice Location Address:
2199 CREST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KLAMATH FALLS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97603-4719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-882-6512
Provider Business Practice Location Address Fax Number:
541-884-3044
Provider Enumeration Date:
09/28/2005