Provider First Line Business Practice Location Address:
700 SUNSET DR
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-1260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-8578
Provider Business Practice Location Address Fax Number:
541-963-8932
Provider Enumeration Date:
07/22/2005