Provider First Line Business Practice Location Address: 
101 DEPOT 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: 
97850-2616
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-963-3772
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/06/2008