Provider First Line Business Practice Location Address:
2210 SHALLOCK AVENUE
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:
97601-4290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-882-1636
Provider Business Practice Location Address Fax Number:
541-882-1799
Provider Enumeration Date:
11/19/2005