Provider First Line Business Practice Location Address:
105 FIR ST
Provider Second Line Business Practice Location Address:
#324 SAC ANNEX BLDG
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:
541-246-3638
Provider Business Practice Location Address Fax Number:
360-844-5184
Provider Enumeration Date:
03/14/2024