Provider First Line Business Practice Location Address:
114 W PALMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAVE JUNCTION
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97523-9667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-592-5099
Provider Business Practice Location Address Fax Number:
541-592-4636
Provider Enumeration Date:
12/15/2005