Provider First Line Business Practice Location Address:
1051 NE 6TH ST
Provider Second Line Business Practice Location Address:
STE 1B
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97526-1190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-956-9595
Provider Business Practice Location Address Fax Number:
541-956-9594
Provider Enumeration Date:
12/16/2006