Provider First Line Business Practice Location Address:
700 SUNSET DR
Provider Second Line Business Practice Location Address:
SUITE A
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:
541-963-8911
Provider Business Practice Location Address Fax Number:
541-962-7110
Provider Enumeration Date:
04/21/2006