Provider First Line Business Practice Location Address:
405 MEADOW CT UNIT A
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:
97850-1271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-799-4110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2009