Provider First Line Business Practice Location Address:
401 ADAMS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-962-7407
Provider Business Practice Location Address Fax Number:
541-962-7479
Provider Enumeration Date:
01/03/2007