Provider First Line Business Practice Location Address:
377 LACLAIR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-756-2057
Provider Business Practice Location Address Fax Number:
541-808-2231
Provider Enumeration Date:
09/27/2007