Provider First Line Business Practice Location Address:
205 N PHOENIX RD
Provider Second Line Business Practice Location Address:
SUITE A
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:
541-732-5760
Provider Business Practice Location Address Fax Number:
541-732-3406
Provider Enumeration Date:
11/01/2006