Provider First Line Business Practice Location Address:
1600 NE 6TH STREET
Provider Second Line Business Practice Location Address:
SUITE S
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97526-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-507-1948
Provider Business Practice Location Address Fax Number:
541-476-0187
Provider Enumeration Date:
09/09/2008