Provider First Line Business Practice Location Address:
105 FIR ST
Provider Second Line Business Practice Location Address:
SUITE 332
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-2661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-805-5502
Provider Business Practice Location Address Fax Number:
541-963-4943
Provider Enumeration Date:
01/30/2009