Provider First Line Business Practice Location Address:
1000 W STANTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-2731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-673-6548
Provider Business Practice Location Address Fax Number:
541-673-8230
Provider Enumeration Date:
10/09/2025