Provider First Line Business Practice Location Address:
242 FERN VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97535-9104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-512-0757
Provider Business Practice Location Address Fax Number:
541-535-6016
Provider Enumeration Date:
12/14/2006