Provider First Line Business Practice Location Address:
1485 NE 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-479-6936
Provider Business Practice Location Address Fax Number:
541-479-6939
Provider Enumeration Date:
06/13/2008