Provider First Line Business Practice Location Address:
1309 NE 6TH 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:
97526-1252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-479-3367
Provider Business Practice Location Address Fax Number:
541-479-0215
Provider Enumeration Date:
02/17/2006