Provider First Line Business Practice Location Address:
105 FIR STREET
Provider Second Line Business Practice Location Address:
SUITE 321
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-4005
Provider Business Practice Location Address Fax Number:
541-663-8144
Provider Enumeration Date:
11/22/2006