Provider First Line Business Practice Location Address:
824 NE A 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:
97526-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-476-4583
Provider Business Practice Location Address Fax Number:
541-479-1515
Provider Enumeration Date:
08/29/2006