Provider First Line Business Practice Location Address:
1502 NORTH PINE ST
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:
541-963-7432
Provider Business Practice Location Address Fax Number:
541-963-0597
Provider Enumeration Date:
10/09/2007