Provider First Line Business Practice Location Address:
700 SUNSET DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-1260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-285-4245
Provider Business Practice Location Address Fax Number:
866-396-7655
Provider Enumeration Date:
02/12/2010