Provider First Line Business Practice Location Address:
1602 4TH ST
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:
97850-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-6224
Provider Business Practice Location Address Fax Number:
541-975-2114
Provider Enumeration Date:
11/09/2006