Provider First Line Business Practice Location Address:
610 SUNSET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-663-3175
Provider Business Practice Location Address Fax Number:
318-387-7919
Provider Enumeration Date:
07/12/2006